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- MAKE A TRADITIONAL CHARTING Patient 4hr Postop, awakens easily, oriented X 3 but groggy, incision site in front of Left ear extending and around the ear and into neck-approximately 6inches in length-without dressing. C. Jones, RN. No swelling or bleeding, bluish discoloration below left ear noted, sutures intact. Jackson-Pratt drain in left neck below ear with 20 ml blood drainage measured. C. Jones RN. Drains remains secured in place with suture and anchored to left anterior chess wall with tape. Patient denied pain buy stated she felt nauseated and promptly vomited 100ml of clear fluid. Pt. attempted to get OOB(out of bed) to ambulate to bathroom with assistance but felt dizzy upon standing. Assisted to lie down in bed. Voided 200ml clear, yellow urine in bed pan. Pt. encourage to deep breath and cough gbt, and turn frequent in bed, Lung sound clear bilaterally. Antiembolism stockings applied to both lower extremities. C. Jones RN Explanation given regarding these preventive…A nurse is preparing a patient for a cesarean section and teachesher the effects of the regional anesthesia she will be receiving.Which effects would the nurse expect? Select all that apply.a. Loss of consciousnessb. Relaxation of skeletal musclesc. Reduction or loss of reflex actiond. Localized loss of sensatione. Prolonged pain relief after other anesthesia wears offf. Infiltrates the underlying tissues in an operative areaA nurse is preparing to administer codeine 30 mg PO every 4 hr PRN to a client for pain. Theamount available is codeine oral solution 15 mg/5 ml. How many ml should the nurse planto administer per dose? (Round the answer to the nearest whole number. Use a leading zero ifit applies. Do not use a trailing zero.)
- A 75-year-old woman is admitted to your unit for evaluation after being found in herapartment unconscious on the floor. She is now awake but moving slowly. Her vital signs arewithin normal limits. 1. In the hospital, it is unrealistic to expect to be able to spend an uninterrupted 30 to 60 minuteswith a single client performing an admission assessment. Which three system would have toppriority for her initial assessment? Discuss why. 2. While gathering relevant history data, what should you do if the client answers with simpleone-word answer or gestures? 3. Because the client may be in significant discomfort from her fall, it is not easy for her to moveabout for the examination. How might you organize your assessment to minimize here need tochange positions frequently? 4. If the client is unable to provide a detailed recent history, what other sources of these datacould you consider?What position should I put my client in ati virtual scenario vital signs4.) What would be the next steps after assessing the patient if the chest pain continued and the patient lost consciousness prior to the arrival of EMS?
- A patient is recei-ing an opioid -ia a PCA pump as part of his postoperati-e pain management program. During rounds, the nurse finds him unresponsi-e, with respirations of 8 breaths/min and blood pressure of 102/58 mm Hg. After stopping the opioid infusion, what should the nurse do next? a )Notify the charge nurse b )Draw arterial blood gases c )Administer an opiate antagonist per standing orders d) Perform a thorough assessment, including mental status examinationA CST is setting up the back table and Mayo stand while the patient is in the OR, and the anesthesia careprovider is preparing to administer general anesthesia. After confirming that the external steamindicator has changed color, the CST places the basin set from the ring stand to the back table andcontinues moving items to their appropriate place. Just before the patient is anesthetized, the circulatornotices water on the inside of the wrap that had been around the basin.1. Should the anesthesia care provider continue with induction?2. What should the CST do to reduce the danger of causing the patient to acquire a surgical siteinfection?3. If the indicator is acceptable, are the contents of the basin sterile?4. Can the CST simply replace the basin set, or is the entire back table considered contaminated?5. What are the reporting requirements in this situation?8. You obtain a set of vitals on the patient above once your establish her ABC's are in tact. The patient has a heart rate of 120, a blood pressure of 80/60, and a respiratory rate of 28. The neighbor says the patient lives alone but hasn't had any problems. She usually is alert, oriented and highly functional. The patient right now is unable to get up on her own and she tells you she is fine, just needs a hand to get up and that. Which of the following are true about your initial management and impression of this patient? Choose all that apply If she has a DNR form (not a MOST or MOLST form) you can leave her at home She likely doesn't have a heat related problem because she has been down on the floor for a while and hasn't been exerting herself Finding out if there are any medication bottles or other evidence of medical problems or medical wishes prior to leaving the house is a good use of time even though the patient is sick One indication for placing her on oxygen would be her fast…
- 4) The nurse is caring fur a client esxperiencing delirium tremens. The health care provider order 2mg of Lorazepam in 500 ML of normal Saline to be Infused Over 3 hours. The drup factur of the tubing available drups per is 15 94s/mL. Calculate the lu flow tate 9tts/min CRecord your ans wer using minute whole nurber)clinical application: angiography Angiography ia t h alsze blood vesseh A s de wer e wnl that absorhs s so that it cants a hes shodow jected near the vesch of te WVhen od to imali the heart and earby vessels, the eltig m lled an ang diogram. When used to vahe ves, the resoltong i ll a venogram. When angogaply ied to mage arteries, the nt is called an arteniognam Angiography is used to vialize the struchure of blood vessels to determine cardhovascular health the perhaps by he de a ve Figure 3 arteogam woch a eted init the fe al ater V ey ch n the be 3 FIGURE 38-5 Arteriogram. Try to identify the arteries on the lines provided and on the blanks in the Lab Report at the end of this exeteise.A nurse enters a patient’s room and examines the patient’s IVfluids and cardiac monitor. The patient states, “Well, I haven’tseen you before. Who are you?” What is the nurse’s bestresponse?a. “I’m just the IV therapist checking your IV.”b. “I’ve been transferred to this division and will be caring foryou.”c. “I’m sorry, my name is John Smith and I am your nurse.” d. “My name is John Smith, I am your nurse and I’ll be car-ing for you until 11 p.m.”