Author Question: An 83-year-old patient was admitted to the hospital for hip replacement surgery after falling at ... (Read 55 times)

abarnes · **on:** Jul 22, 2018

An 83-year-old patient was admitted to the hospital for hip replacement surgery after falling at home and breaking her hip. She has developed pneumonia while in the hospital.

The nurse caring for the patient is concerned about her hip healing but is more concerned about her ineffective airway clearance related to pain, increased tracheobronchial secretions, and fatigue. The nurse encourages the patient to breathe deeply and cough during her shift. This is an example of which of the following American Nurses Association Standards of Practice? A. Assessment
B. Nursing diagnosis
C. Planning
D. Outcomes identification

Question 2

A postoperative patient stands up and begins to feel faint. The nurse should do which of the following? Select all that apply.

A. Have the patient lie down.
B. Have the patient try to stand again later.
C. Attempt to listen to the Korotkoff sounds.
D. Listen to the patient's apical pulse with the bell of a stethoscope.
E. Expect the sitting blood pressure to be lower than the standing blood pressure.

Tabitha_2016 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
The definition of planning by the ANA Standards of Practice is that the registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.

Answer to Question 2

A, B
Orthostatic hypotension occurs when a patient with a normal blood pressure develops symptoms (e.g., lightheadedness or dizziness) and low blood pressure when rising to an upright position. Korotkoff sounds are heard as rhythmic tapping that corresponds to the pulse. The apical pulse is auscultated with the diaphragm, which hears high-pitched sounds. The sitting blood pressure will be higher than the standing blood pressure.