The nurse is caring for a patient who is slow to awaken following ...

[mrsjacobs44]

The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway.
 
  Which intervention is the most appropriate for the patient to improve oxygenation?
  a.
  Insert an oral airway.
  b.
  Lower the head of the bed.
  c.
  Turn the patient's head to the side.
  d.
  Monitor the patient's pulse oximetry.

Question 2

The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88 on 4 L of oxygen.
 
  What is the priority intervention of the nurse?
  a.
  Administer the ordered intravenous diuretic.
  b.
  Prepare for insertion of a chest tube.
  c.
  Suction secretions from the patient's respiratory tract.
  d.
  Have the patient use the ordered incentive spirometer.

[atrochim]

Answer to Question 1

ANS: A
An oral airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear the airway.

Answer to Question 2

ANS: A
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine and relieve the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or improve the patient's symptoms.

[mrsjacobs44]

TYSM

[Viet Thy]

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