A patient has been admitted to the neurological unit from the PACU after successful neurosurgery to remove a brain tumor. The nurse's admitting assessment reveals that the patient's gag reflex has not yet fully returned.
The nurse should recognize that this assessment finding has the potential to cause which of the following nursing diagnoses?
A) Risk for aspiration
B) Impaired spontaneous ventilation
C) Dysfunctional ventilator weaning response
D) Imbalanced nutrition: less than body requirements
Question 2
A urology nurse is caring for a male patient admitted to the unit with bladder distention from prostatic hypertrophy. The health care provider orders placement of an indwelling urinary catheter.
The nurse and urologist are both unsuccessful in catheterizing this patient due to the prostatic obstruction. What approach does the nurse anticipate the health care provider using to drain the patient's bladder?
A) Insertion of a suprapubic catheter
B) Scheduling the patient immediately for surgery to relieve the bladder obstruction
C) Application of warm compresses to the perineum to assist with relaxation, which will result in the patient voiding on his own
D) Medication administration to relax the bladder muscles and attempting catheterization in 6 hours
Measuring Patient Height
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