During change-of-shift report on a medical unit, the nurse learns ...

[mpobi80]

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
 
  a. Give the prescribed PRN sedative drug.
  b. Offer reassurance and reorient the patient.
  c. Use pulse oximetry to check the oxygen saturation.
  d. Notify the health care provider about the patient's status.

Question 2

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse?
 
  a. Only continuous IV opioids have been ordered.
  b. The patient does not respond to verbal stimulation.
  c. There is no cough or gag when the patient is suctioned.
  d. The patient's oxygen saturation fluctuates between 90 to 93.

[chinwesucks]

Answer to Question 1

ANS: C
Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about oxygen saturation.

Answer to Question 2

ANS: A
Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The oxygen saturation is adequate.