Author Question: The nurse will be caring for a patient who has just arrived on the medical-surgical unit following ... (Read 34 times)

notis · **on:** Jul 23, 2018

The nurse will be caring for a patient who has just arrived on the medical-surgical unit following surgical repair of his fractured right ankle. Which is the priority action of the nurse when the patient arrives on the unit?

a. Instruct the patient how to call for assistance using the call light.
b. Assess the color and warmth of the toes on the patient's right foot.
c. Determine when the patient's next pain medication is due.
d. Check pulse oximetry and obtain a full set of vital signs.

Question 2

The nurse is caring for a postoperative patient who is recovering from abdominal surgery. The nurse notes that the patient's breath sounds are clear but diminished, shallow, and slightly labored.

The patient's pulse oximetry is 96 on room air. What is the priority action of the nurse?
a.
Administer a dose of the prescribed pain medication.
b.
Administer 2 L of oxygen via nasal cannula.
c.
Obtain an order from the physician for a chest x-ray.
d.
Ensure that the patient is using the spirometer 10 times every hour.

cadimas · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: D
Checking pulse oximetry and vital signs is the priority action when the patient first arrives on the medical-surgical unit from the postoperative area. The other actions can wait until the vital signs have been obtained.

Answer to Question 2

ANS: D
The assessment findings indicate that the patient most likely has atelectasis, so the nurse should ensure that the patient is using the incentive spirometer 10 times every hour to facilitate expansion and reinflation of alveoli. Administering prescribed pain medication is not the priority and may further suppress the patient's respiratory drive. The patient's pulse oximetry is 96 on room air so supplemental oxygen is not needed. A chest x-ray may be ordered if the patient's condition worsens or does not improve with regular spirometer use.