Question 13 type mcsa assessment of a patient

This preview shows page 10 - 12 out of 28 pages.

Question 13Type:MCSAAssessment of a patient postarthroplasty reveals tachypnea, air hunger, hypoxia, O2sat of 86%, declining mentalstatus, and petechiae. What is the nurse’s priority action?1.Apply oxygen at 3 to 4 liters /minute.2.Call a code for potential cardiac arrest.3.Prepare the patient for immediate intubation and mechanical ventilation with PEEP.4.Raise the head of the bed (HOB) and encourage coughing every hour.Correct Answer:Rationale 1: Application of oxygen would improve the availability of oxygen within the lungs but would notimprove the perfusion at the alveolar capillary membrane.Rationale 2: Calling for a code related to cardiac arrest is not appropriate at this time because the heart is not theproblem; the pulmonary status should be addressed first.Rationale 3: The symptoms are related to severely compromised pulmonary status, probably acute respiratorydistress syndrome (ARDS), which is related to a fat embolus blocking the pulmonary vessel and inactivatingsurfactant. Intubation and mechanical ventilation with PEEP (positive end-expiratory pressure) are needed tomaximize air exchange and treat symptoms until the condition resolves.3
Rationale 4: Raising the HOB will improve gas exchange slightly, but the problem is not expansion of the chest,so the condition will not improve.Global Rationale:Cognitive Level:AnalyzingClient Need:Physiological IntegrityClient Need Sub:Physiological AdaptationNursing/Integrated Concepts:Nursing Process: ImplementationLearning Outcome:50-4Question 14Type:MCSAA patient experienced a cerebral spinal fluid leak after spinal surgery. The leak has just been treated with a bloodpatch. What is the nurse’s priority action?4
Global Rationale:Cognitive Level:AnalyzingClient Need:Physiological IntegrityClient Need Sub:Physiological AdaptationNursing/Integrated Concepts:Nursing Process: ImplementationLearning Outcome:50-4Question 15Type:MCSA

Upload your study docs or become a

Course Hero member to access this document

Upload your study docs or become a

Course Hero member to access this document

End of preview. Want to read all 28 pages?

Upload your study docs or become a

Course Hero member to access this document

Term
Winter
Professor
N/A
Tags
Nursing, Orthopedic surgery, Global Rationale, Bone fracture, callus, Compartment syndrome

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture