The nurse in a skilled nursing facility is caring for an ...

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The nurse in a skilled nursing facility is caring for an 80-year-old patient who develops a productive cough with pink, frothy sputum. Which independent interventions should the nurse implement immediately? (Select all that apply.)
 
  a. Limit the patient's activity.
  b. Administer morphine.
  c. Administer lasix.
  d. Place the patient in high Fowler position.
  e. Weigh the patient daily.

Question 2

The nurse is caring for patient who is postoperative after a bladder repair. The patient complains of pain. Which independent nursing intervention is best?
 
  a. Administer an analgesic medication.
  b. Apply a cold compress to the surgical site.
  c. Dim the lights in the room.
  d. Irrigate the drainage tube.

[enass]

Answer to Question 1

A, D
Acute pulmonary edema (acute left ventricular failure) is a medical emergency that must be treated promptly. The patient with this condition has severe dyspnea; a cough productive of fro-thy, pink-tinged sputum; tachycardia; and moist, bubbling respirations with cyanosis. Nursing interventions for acute pulmonary edema include placing the patient in high Fowler position to relieve the dyspnea; administering oxygen, diuretics, morphine, and other prescribed drugs; li-miting and monitoring activity; and assessing cardiopulmonary status. Limiting activity and placing the patient in high Fowler do not require a physician's order and should be implemented immediately. Acute pulmonary edema is a medical emergency, and activity necessary to obtain a daily weight is not indicated at this time. Administering morphine and diuretics are dependent nursing interventions.

Answer to Question 2

B
Cold application to the surgical site applies the best independent intervention. Dimming the lights may also help to create a more comfortable environment. Administering an analgesic and irrigating the drainage tube are interventions that require a physician's order.

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Thank you

[enass]

Happy to help you