Author Question: A 68-year-old male patient is brought to the emergency department (ED) by ambulance after be-ing ... (Read 47 times)

futuristic · **on:** Jun 25, 2018

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after be-ing found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?

a. Check oxygen saturation.
b. Assess pupil reaction to light.
c. Verify Glasgow Coma Scale (GCS) score.
d. Palpate the head for hematoma or bony irregularities.

Question 2

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a crani-otomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

a. The staff nurse assesses neurologic status every hour.
b. The staff nurse elevates the head of the bed to 30 degrees.
c. The staff nurse suctions the patient rou-tinely every 2 hours.
d. The staff nurse administers an analgesic before turning the patient.

tmlewis4706 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Airway patency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

Answer to Question 2

ANS: C
Suctioning increases intracranial pressure, and should only be done when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.