The two scales that are recommended for assessment of agitation ...

[berenicecastro]

The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the
 
  a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS).
  b. Ramsay Scale and Motor Activity Assessment Scale (MAAS).
  c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS).
  d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale (MAAS).

Question 2

A tracheostomy patient is experiencing regurgitation of tube feeding formul
 
  a. The nurse's first priority should be
 
  a. checking to make sure the tracheostomy cuff is inflated during tube feedings.
  b. placing the patient in the right lateral decubitus position to promote gastric emptying.
  c. discussing the use of metoclopramide to facilitate gastric motility with the physician.
  d. placing the patient in prone position to improve draining from mouth.

[mochi09]

Answer to Question 1

C
The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the SAS and the RASS.

Answer to Question 2

A
When regurgitation of formula is an issue, the following interventions can be used as appropriate: keep the cuff of the endotracheal or tracheostomy tube inflated during feedings to prevent aspiration; elevate the head to 30 to 45 degrees during feedings unless contraindicated; if head cannot be raised, position the patient in the right lateral position or prone position to improve drainage of vomitus from the mouth; and consider giving metoclopramide to improve gastric emptying.