It is important to avoid increasing the client’s agitation by speaking and moving slowly. Any sudden moves or speaking too quickly may cause agitation. Walking up behind the client may cause the client to become startled. Remaining at the entrance of the room may make the client feel alienated. If the client’s agitation is not addressed, it will only increase.
Smoke detectors are important to use; however, the batteries need to be changed yearly.
Syringes should never be recapped in any circumstances for fear of getting stuck with a contaminated needle. Used syringes should always be placed in a sharps container immediately afterward to prevent injury from a needle stick.
Restraints should never be applied tightly because it could impair the circulation. A safety (hitch) knot may be used on the restraint because it can easily be released in an emergency. Restraints must be released at least every 2 hours (or per agency policy) to inspect the skin for abnormalities and to provide range-of-motion exercises. The call light must always be at the client’s reach in case the client needs assistance.
A mask would offer full protection of the nose and mouth. Goggles would protect the eyes from getting injured. A gown would protect the nurse’s uniform. A cap would protect the nurse’s hair.
Personal protective equipment, called particulate respirators, is required for all health care workers entering a tuberculosis isolation room. When fitted and used properly, these respirators filter droplet nuclei. It is important that no air escapes around the nose while wearing the respirator. The strap needs to be adjusted if air is escaping. It is important to exhale forcefully while placing both hands over the apparatus. It is necessary to perform a fit check each time the nurse uses the mask.
The victim should be placed or kept in a supine position because flames may otherwise spread to other parts of the body, causing more extensive injury. Flames can be extinguished by rolling the client on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water.
Proper hand washing is the best way to prevent the spread of infection. Reading the policy and procedure manual does not guarantee that infection will not spread. All procedures do not require sterile technique. Clean technique alone is not always appropriate.
The inside of the container is sterile and sterility must be maintained. If fingers touch the inside, this would contaminate the container. The meatus should be cleansed from front to back (toward the anus). Upward strokes would bring bacteria from the anal region to the area of the urethra. The labia should remain open during the procedure. The client should urinate a small amount into the toilet before urinating in the specimen container to allow some of the organisms near the meatus to leave the area.
Hands must always be washed (even though sterile gloves are used) to keep germs from spreading. The inside wrapper makes an excellent area for usage because it is sterile. If the gloves touch anything unsterile, they must be considered contaminated, and a new package must be used. The sequence for donning gloves is up to the individual as long as sterile technique is maintained.
The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other areas. Gloves are considered the dirtiest item and therefore, must be removed first. Hands should be washed after removing the equipment to remove any unwanted germs still present. Ungloved hands should be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves.
Nocturia, decreased force, and difficulty initiating urine stream are all early signs of benign prostatic hypertrophy. Hematuria may occur as a later sign.
Petrolatum provides the most effective moisturizing by forming an occlusive barrier on the skin and reducing water loss. Creams and lotions are mostly water-based, less occlusive, and less likely to reduce skin dryness than petrolatum-based products.Bath oils are not as effective as a petrolatum-based product.
Scald, tar, or asphalt burns should be treated by immediate cooling with water, if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may occur. No attempt is made to remove tar from the skin at the scene of the accident.
When these two medications are taken together, the bronchodilator (Ventolin) should be given first to open the airways. This will allow better penetration of the corticosteroid (Beclovent) into the bronchial tree. Inhalers do not need to be refrigerated, and no medication should be taken past the expiration date.
High-pitched tinkling sounds are indicative of an intestinal obstruction, especially in the early phase, when the bowel is attempting to move gastrointestinal contents past the area of obstruction. Absent or diminished sounds may be indicative of a paralytic ileus. Resonance is not a finding in auscultation.
Diminished or absent pupillary response and decreased retinal blood supply can cause night blindness, inability to see due to glare, and deficits with depth and color perception. Using high gloss paint on walls will increase glare and make it harder for the client to see.
The discs in the spine compress as part of normal age-related changes and cause a decrease in the client’s height.
The older client may not present with the usual signs and symptoms of illness. Due to their lower than normal body temperature, an early sign of fever would be a temperature of 99° F degrees rectally. Blood-tinged sputum is usually a sign of congestive heart failure. In later stages of pneumonia, the respiratory rate increases in an attempt to compensate for poor oxygen exchange. Poor skin turgor is a sign of dehydration.
Arteriosclerosis is described as a thickening and loss of elasticity of the arteries
Atherosclerosis is a deposit of fatty plaques linking the arteries.
Phenobarbital is a barbiturate used to manage seizure disorders. Drowsiness is a common side effect of phenobarbital. Blurred vision is not a side effect of this medication. Seizure activity could occur from abrupt withdrawal of medication therapy, or as a toxic effect. Hypocalcemia is a rare toxic effect.
Difficulty falling asleep is one type of sleep pattern disturbance. Somnambulism (sleepwalking), apraxia (inability to perform purposeful movements), and nocturia (excessive nighttime urination) are not indicators of a disturbed sleep pattern.
Destruction of alveolar walls is a characteristic of chronic obstructive pulmonary disease and is not a normal age-related change found in the older client. As aging occurs, lung tissue becomes less elastic and more rigid (not less rigid), alveolar membranes thicken (not thin), and ciliary movement is reduced.
Until the client is ready to learn, teaching sessions will be ineffective. Teaching should be in short sessions, early in the day, when the client is well rested. It is important to include the client in the development of the teaching plan, and set priorities with the client. Varied teaching methods are best, such as verbal instruction, with visual aids, and the provision of written material for later reference.
Regular insulin and NPH insulin can be mixed together in the same syringe for administration. Regular insulin is drawn up before the NPH insulin. Insulin is usually administered 15 to 30 minutes before a meal. To mix the NPH Insulin suspension, the vial should be gently rotated. Shaking introduces air bubbles into the solution.
New influenza vaccines are developed every year based on predictions of which strains of the virus will be active. Clients should be advised to get the vaccine every year.
CAD occurs due to accumulation of fatty plaque in the coronary arteries or as a result of arteriosclerotic changes. Elevated serum cholesterol and triglyceride levels (hyperlipidemia) play a major role in the development of CAD.
CAD may go unrecognized for a period of time in persons with a sedentary lifestyle because adequate blood flow to the myocardium may be maintained despite the disease. However, during times of emotional stress and/or increased physical activity the diseased coronary arteries may not be able to supply the myocardium with adequate blood. The inadequate perfusion of the myocardium, referred to as ischemia, causes pain although no damage to the heart muscle occurs. Necrosis is a result of prolonged oxygen deprivation to the myocardium and tissue death (myocardial infarction) occurs.
Reducing the demands on the heart by encouraging rest and relaxation is important for the hospitalized client with CAD. Oxygen therapy is frequently ordered for cardiac clients to provide supplemental oxygen. A diet low in salt and fat is also prescribed.
During the post–cardiac catheterization period, priorities of nursing care include frequent monitoring of the blood pressure and pulse. The catheter insertion site is checked frequently for signs of bleeding and swelling. Distal pulses are also assessed. Potassium level, temperature, and urine output should also be monitored but are not the priority of the items identified in the options.
The dye used during the catheterization contains iodine, so any allergies to shellfish or iodine should be reported immediately to prevent allergic complications.
HDLs are considered to be the “good” cholesterol and LDLs are considered to be the “bad” cholesterol. LDLs come mainly from animal fats. Elevated cholesterol and triglyceride levels are not desirable.
Foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat should be avoided because they contribute to increases in low-density lipoproteins. The use of polyunsaturated oils, skim milk, and complex carbohydrates is recommended to control hypercholesterolemia.
Nonmodifiable risk factors for CAD are those that cannot be controlled or changed, including age, gender, and ethnicity. Modifiable risk factors can be controlled, and these include factors such as cholesterol levels, hypertension, cigarette smoking, and obesity.
Nitroglycerin is a vasodilator used to increase coronary artery blood flow. The side effects of nitroglycerin include postural hypotension, flushing, headache, dizziness, and rash. Monitoring the blood pressure is most important.
Rest and relaxation are crucial for clients with angina because stress and emotional tension can trigger episodes of pain.
Angioplasty involves using a balloon-tipped catheter to displace or flatten the plaque built up along the arterial walls, thereby enlarging the diameter of the vessel. There is a chance for a small piece of the plaque to become dislodged, which could create an embolus. Reactions from the contrast would occur most likely immediately, not when the client returns to the nursing unit. Cerebral hemorrhage and increased intraocular pressure are not directly related to post-angioplasty complications.
Ischemia may be detected on an ECG by changes in the S-T wave or by T wave inversion. Ischemia represents a decreased amount of oxygen to the myocardium.
Clients experiencing angina should not consume caffeinated beverages because of the vasoconstrictive effect associated with caffeine.
In a client with unstable angina, the client requires plenty of rest and relaxation to prevent decreased blood supply to the myocardium as a result of increased demands. Large meals are contraindicated due to the increased metabolic requirement for digestion and consumption.
Lithium and sodium, similar in chemical structure, compete to occupy sites within the body. Because of this, when normal sodium levels are reduced, lithium tends to be reabsorbed. When this happens, it increases the amount of lithium in the body causing side effects such as fever, increased sweating, diarrhea, or increased urination. For this reason, the nurse instructs the client to drink 2 to 3 liters of water each day and eat a diet that is adequate in sodium. Once the client's lithium level is stabilized (usually within 2 weeks), blood lithium levels should be drawn every 1 to 2 months for evaluation.
Successful angioplasty may need to be repeated due to abrupt closure of the artery. Following recommended dietary and lifestyle changes assist to prevent further atherosclerosis.
The LAD perfuses most of the left ventricular muscle mass and the septum
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