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

Answer of first question : (b) ineffective cerebral perfusion and peripheral tissue perfusion, r/t low blood volume, cuased by excessive bleeding m/b low BP, Poor turgor, dry and pale skin & mucous membrane, and confusion.

Priority nursing diagnosis should be what that could be lethal to patient right now. Option (a) is not dangerous right now. Option (c) is diagnosis but not be taken at priority. As pain management would not be reason of ICU shifting. It can be managed afterward. Option (d) which breathing difficulty is important to be look after in ICU it may beworsen. But it is due to smoking and no any intervention are performed during surgery that cause difficulty breathing. HoweHer it would be second priority Option (b) is most dangerous for the patient right now. And should be taken as priority.

Answer of second question :: (c)patient will increase fluid intake to 3500ml/24 hours

the case is same as above. And first priority of treatment must be correct blood pressure. Remaining interventions can be started after intiate restoring the blood pressure. As the patient had lost blood in surgery and turgor and pale skin showing that there is poor perfusion. Patient is confused and disoriented meanmeans poor perfusion in brain too. So fluid must be on first priority. Second priority to correct breathing difficulty. But it not the answer neither in the option.