Chapter 18 Notes, WGU C825 Intro to Nursing: Lab Prep Questions & Answers. 100% Accurate . (2024/25 exam UPDATES. APPROVED)

Chapter 18 Notes, WGU C825 Intro to Nursing: Lab Prep Questions & Answers. 100% Accurate A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) A. The family comes to visit the patient. B. The patient expresses concern about pain control. C. The patient's vital signs change, showing a drop in blood pressure. D. The charge nurse approaches the nurse and requests a report at end of shift. - -B. The patient expresses concern about pain control. C. The patient's vital signs change, showing a drop in blood pressure. A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first? A. Reconnect the drainage tubing B. Inspect the condition of the IV dressing C. Improve the patient's comfort and turn onto her side D. Obtain the next IV fluid bag from the medication room - -A. Reconnect the drainage tubing A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.) A. Patient will be turned every 2 hours within 24 hours