The nurse receives a call from the spouse of a client with ...

[pepyto]

The nurse receives a call from the spouse of a client with chronic alcoholism. The spouse reports that the client has been having hallucinations, and just had a brief seizure. The nurse directs the spouse to:
 
  1. Give him a glass of alcohol and see if he gets better immediately.
  2. him about any medications he might have taken.
  3. Call the physician and inform her of the client's condition.
  4. Call EMS and have him taken to the hospital Emergency Department.

Question 2

The nurse is caring for a postoperative client and gathers the following data: temperature 36.
 
  2C, pulse 104, respirations 8, oxygen saturation 92, pain level of 2, dressing is clean and dry, breath sounds reveal fine rales in the bases bilaterally. What is the nurse's priority intervention? 1. Ask the client to deep-breathe and cough.
  2. Administer narcotic analgesic for pain.
  3. Notify the doctor of the client's need for increased fluids.
  4. Administer oxygen.

[miss_1456@hotmail.com]

Answer to Question 1

4
Rationale: This client likely is experiencing alcohol withdrawal and delirium tremens. The client requires immediate medical intervention, and should be taken to the local Emergency Department by ambulance to prevent further symptoms. Administering alcohol would reduce the symptoms but also would not support recovery.

Answer to Question 2

1
Rationale: The client's respiratory rate is low, possibly secondary to narcotic analgesics. Asking the client to deep-breathe and cough will help to improve oxygenation and clear secretions from the airways. If, after coughing and deep-breathing, the client returns to the same level of sedation and respiratory depression, the nurse will inform the RN. There is no need to increase fluids or administer oxygen, as the elevated pulse rate is not uncommon after surgery, and is not significantly elevated to require treatment.