Author Question: On admission to the PACU, in which manner does the nurse position the patient who has no orthopaedic ... (Read 32 times)

BRWH · **on:** Jul 22, 2018

On admission to the PACU, in which manner does the nurse position the patient who has no orthopaedic or neurological restrictions?

a. With the bed flat and the patient's arms to the sides
b. With the patient's neck flexed and body in prone position
c. With the patient in side-lying position
d. With the patient's arms crossed over the chest and the bed in high Fowler's position

Question 2

A patient has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, which of the following nursing diagnoses is identified by the nurse?

a. Powerlessness
b. Self-care deficit
c. Tissue integrity impairment
d. Knowledge deficit of hygiene practices

epscape · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C

Feedback
A Positioning the patient with the bed flat and the patient's arms to the sides would not best facilitate a patent airway.
B The patient's neck should not be flexed, as this may occlude the airway.
C In the postanaesthetic patient, the tongue causes a majority of airway obstructions. Ongoing assessment of airway patency is crucial. Patients are often kept in side-lying positions until the airway is clear.
D This is not the best position to promote respirations. The patient's arms should never be positioned over or across the chest, because this reduces maximal chest expansion.

Answer to Question 2

B

Feedback
A Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of Powerlessness.
B The patient who is unable to complete bathing and grooming independently has a nursing diagnosis of Self-care deficit.
C Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of Tissue integrity impairment.
D There is no indication that this patient has a Knowledge deficit of hygiene practices.