Question

16. You are receiving a patient from recovery (PACU). He is a 71-year-old man who just underwent a surgical repair of a fractured femur. Medical history: hypertension, emphysema, and a 40 pack-years of smoking. Patient has productive cough and slightly labored breathing Surgery was complicated by excessive bleeding, and he is receiving IV fluids. Patient has poor turgor and BP is stbll very low. Skin and mucous membranes are dry and pale. Patiet complains of pain 6/10 at the surgical site. He is widowed, and his three children are scattered throughout the United States. He receives a community service for meals (Meals on Wheels) When you recheck BP find it even lower, and patient s progressively confused, disoniented X3, the doctor orders patient transfer to Intensive Care. Which is the priority nursing diagnosis for this patient? a Risk for loneliness, rit living alone Acute pain, rt surgical incision, m/b patient's statement of pain 6/10 Ineffective Cerebral and Peripheral Tissue Perfusion, low blood volume, caused by excessive bleeding, m/b low BP. poor turgor, dry and pale skin and mucous membranes, and confusion b. Ineffective breathing pattern, related to decreased lung expansion secondary to chronic airflow limitation, m/b labored breathing d. You are receiving a patient from recovery (PACU) He is a 71-year-old man who just underwent a surgical repair of a fractured femur. Medical history: hypertension, emphyse labored breathing Surgery was complicated by excessive bleeding, and he is receiving IV fluids. Patient has poor turgor and BP is still very low. Skin and mucous membranes are dry and pale. Patiet complains of pain 6/10 at the surgical site. He is widowed, and his three children are scattered throughout the United States. He receives a community service 17. ema, and a 40 pack-years of smoking. Patient has productive cough and slightly for meals (Meals on Wheels). When you recheck BP find it even lower, and patient confused, disoriented X3, the doctor orders patient transfer to Intensive Care. Which is a correct and a Nurse will assess patient for pain e Patient will ncrease fluids intake b. Nurse will reassess patient's vital d Nurse will turn on patient's TV all to 3500 mL/24 hours signs every 2 hours the time so patient does not feel alone

Answer 1

16. The priority nursing diagnosis for this patient is -

b.Ineffective cerebral and peripheral tissue perfusion related to low blood volume caused by excessive bleeding , m/b low BP ,poor turgor , dry and pale skin , mucous membrane and confusion.

17. The correct and priority nursing intervention is -

b.nurse will reassess patients vital sign every 2 hours.