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Author Question: The nurse working on a high acuity medical-surgical unit is prioritizing care for four patients who ... (Read 112 times)

cartlidgeashley

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The nurse working on a high acuity medical-surgical unit is prioritizing care for four patients who were just admitted. Which patient should the nurse assess first?
 
  a. The NPO patient with a blood glucose of 80 who just received 20 units of 70/30 Novolin insulin
  b. The patient with a pulse of 58 who is about to receive digoxin (Lanoxin)
  c. The patient with a blood pressure of 136/92 with complaints of a headache
  d. The patient with a mild allergy to penicillin who is receiving an infusion of cefa-zolin (Ancef)

Question 2

Clopidogrel (Plavix), in comparison with aspirin, is less likely to cause which adverse effect(s)? You may select more than one answer.
 
  a. Intracranial hemorrhage
  b. Headache
  c. Rash
  d. GI bleeding
  e. Ataxia



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ebenov

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Answer to Question 1

A
The NPO patient with hypoglycemia who just received 70/30 Novolin insulin takes priority, be-cause this patient needs to consume a good source of glucose immediately, or perhaps the NPO status will be discontinued for this shift.
The digoxin may be withheld for the patient with a pulse of 58, but this is not a priority action.
The patient with a headache needs to be followed up, but because the blood pressure is 136/92, the headache is not life threatening.
The patient with the mild PCN allergy probably will not have a reaction to the cefazolin, because the PCN allergy is only mild. It is not a life-threatening situation if the nurse cannot immediately discontinue the cefazolin.

Answer to Question 2

a, d





 

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