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You are the nurse on a medical unit taking care of a 50-year-old…

 

You are the nurse on a medical unit taking care of a 50-year-old man, S.W., who was admitted 18 hours ago with peptic ulcer disease secondary to suspected chronic alcoholism. You enter S.W.’s room and witnessed new onset of generalized weakness upper and lower extremity. Identify nursing interventions that are appropriate for S.W. at this time

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Select all that apply

  1. Assess respiratory status, including airway patency; effort, lung sounds; use of accessory muscles and color of skin, lips, and nail beds.
  2. Monitor ability to handle secretions and assess gag, cough, and swallow reflexes.
  3. Monitor for weakness or paralysis, dysphasia, or visual disturbances.
  4. Check blood glucose and request serum laboratory tests as prescribed.
  5. Monitor urine for red or cola color, which might signal rhabdomyolysis or myoglobinuria from muscle damage

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