A nurse is caring for a client who is intubated and has an ...

[bclement10]

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort?
 
  a. Allow family members to remain at the bedside.
  b. Ask the family if the client would like a fan in the room.
  c. Keep the television tuned to the client's favorite channel.
  d. Speak loudly to the client in case of hearing problems.

Question 2

A nurse is caring for four clients. Which client should the nurse assess first?
 
  a. Client with an acute myocardial infarction, pulse 102 beats/min
  b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
  c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr
  d. Client who is post coronary artery bypass, potassium 4.2 mEq/L

[Christopher]

Answer to Question 1

ANS: A
Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

Answer to Question 2

ANS: B
The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.