Apart from repositioning every three to four hours, all options are correct. The patient has to be adjusted at least once per hour or two if they are not able to move or ambulate.
A semicomatose patient is susceptible to aspiration (from fluids collecting in the mouth or from vomiting, which is a typical sedation-related side effect). Repositioning the patient on their side, ideally the left, will aid in improving cardiovascular circulation and reducing the chance of aspiration.
The ideal antiseptic is chlorhexadine due to its broad spectrum properties. Skin bacteria are instantly killed by chlorhexadine, and it has residual effect that lasts for a few hours after application. Unlike iodophor, it is not affected by contact with organic substances. Acetone and alcohol cause the skin to become dry.
Sponge recounts are used to find inaccuracies, which are frequently caused by inaccurate counts or lost sponges. If there are any differences, a straightforward recount generally clears the air and notifies the surgeon of any inaccuracies. If an error is verified, an occurrence report must be filed. The next step is to get in touch with the surgical management if accurate counts aren't kept up to date.
Before assuming that a client's perplexity is due to hypoxemia, the nurse must rule that out. A patient with a compromised airway might be confused as a result of hypoxemia. While vital assessments in the postoperative phase include cardiac rhythm, degree of awareness, and anxiety, these are rarely the first things to look at when a client presents confused.
The nurse must keep a careful eye on the patient's urine production. At least 30 milliliters per hour of urine should be produced in a 24-hour period. The patient in this instance is only urinating 12.5 ml per hour.
"Sinus tachycardia is a common dysrhythmia that frequently requires treatment of the underlying etiology. Atropine is a medication that is frequently used to treat sinus bradycardia, which is a condition brought on by worry. For sinus tachycardia, one would not use heated blankets and place a patient in the left lateral position."
While waiting for the surgeon, the nurse should keep an eye on the sterile field. The potential for contamination during the drape removal process is the reason the nurse shouldn't cover the sterile field. To keep an eye on the sterile field, a staff person needs to stay in the operating room at all times. The sterile field does not need to be destroyed because there will be little delay.
After a patient resumes solid food, they should have a bowel movement within 48 hours. The patient may be experiencing constipation and appropriate interventions must be followed.
Since potassium is necessary for the proper operation of all muscles, including the heart muscle, this low potassium level should be reported to the healthcare provider.
With one exception—"The patient inhales slowly on the device and maintains the flow indicator between 600 and 900 level"—all of the options are incorrect. The other choices don't show you how to operate the incentive spirometry correctly.
