To ensure safe administration of medication, the nurse allows the client to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.
Cardioversion is similar to defibrillation with two major exceptions: (1) the countershock is synchronized to occur during ventricular depolarization (QRS complex), and (2) less energy is used for the countershock. The rationale for delivering the shock during the QRS complex is to prevent the shock from being delivered during repolarization (T wave), often termed the “vulnerable period.” If the shock is delivered during this period, the resulting complication is ventricular fibrillation. It is crucial that the defibrillator is set on the “synchronous” mode for a successful cardioversion
Protamine sulfate is the antidote for heparin sodium. Phytonadione is the antidote for warfarin (Coumadin). Fresh frozen plasma may also be used for bleeding related to warfarin (Coumadin) therapy. Streptokinase is a thrombolytic agent used to dissolve blood clots.
Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators are not normally prescribed for the client with cardiomyopathy.
Clients with valvular disease are placed on anticoagulants to prevent thrombus formation and possible stroke. The importance of use of an electric razor is to prevent cuts and possible bleeding.
Immediately following a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. Placing the client in the Fowler’s position (flexion) increases the risk of occlusion or hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. The precatheterization medications are needed to treat acute and chronic conditions.
Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings. The specimen is obtained early in the morning whenever possible, because increased amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production.
Mobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids should not be restricted.
The least reliable method for determining accurate placement of the NG tube is to place the end of the tube in water to observe for bubbling.
The fecal-oral route is the mode of transmission of an intestinal parasitic disease. Standard precautions prevent the transmission of infection. Cleaning with soap and water is not as effective as the use of bleach. Water and fresh foods can be vehicles for transmission, but municipal water sources are usually safe. Some fresh foods do not need to be cooked as long as they are washed well and provided that they weren’t grown in soil contaminated with human feces.
A cesarean delivery can reduce the risk of neonatal infection with a mother in labor who has herpetic genital tract lesions. Intact membranes provide another barrier to transmitting the disease to the neonate. There is no need to limit visitors or maintain isolation, although standard precautions should be maintained.
The nurse would test the patency of the balloon before insertion. If the balloon is not patent and the catheter was inserted without checking patency, it would need to be removed and replaced (remember this procedure places the client at risk for infection, and repeated insertions need to be avoided). The catheter should be advanced for 1 to 2 more inches beyond the point where the flow of urine is first noted. This ensures that the catheter balloon is fully in the bladder before it is inflated. The drainage bag is placed lower than bladder level (without kinks) in the tubing to ensure drainage and prevent backflow of urine. The balloon is inflated per the manufacturer’s instructions and is not overinflated.
A client who is moderately depressed and has only been hospitalized 2 days is unlikely to have such a dramatic cure. When a mood suddenly lifts, it is likely that the client may have made the decision to harm him or herself. Suicide precautions are necessary to keep the client safe.
At shift change, there is often less availability of staff. The psychiatric nurse and staff should increase precautions for suicidal clients at that time. Weekends are also high-risk times, not weekdays. The night shift also presents a high-risk time.
During the transfer of the client after the surgical procedure is complete, the nurse should avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid changes in position should be avoided because these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of the anesthesia; therefore, the client should not move self. Safety belts can prevent the client from falling off the stretcher.
Anticoagulant therapy predisposes the client to injury because of the agent’s inhibitory effects on the body’s normal blood-clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of activities of daily living and with other activities.
Until the cause of the acute abdomen is determined and a decision about the need for surgery is made, the nurse would question an order to give a narcotic analgesic because it could mask the client’s symptoms. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of a nasogastric tube may be helpful to provide decompression of the stomach.
A nurse must uphold the client’s rights and does not give any information regarding a client’s care needs to anyone who is not directly involved in the client’s care. To request that the friend come for teaching is a direct violation of the client’s right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer the call to the nurse manager and social worker again assumes that the friend’s assistance and involvement is desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential.
The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. There is no legal obligation to inform the client of the nurse’s personal objections to the client. Refusal to provide care may be acceptable if that refusal does not put the client’s safety at risk and the refusal is primarily associated with religious objections, not personal objection to lifestyle or medical diagnosis. The nurse also has an obligation to observe the principle of nonmaleficence (causing nor allowing harm to befall the client).
The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated. Heparin administered subcutaneously does not require an infusion device. After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract.
A living will addresses the withdrawal or withholding of life sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness.
Gloves will keep the child from scratching the open lesions from chickenpox. Generous amounts of any topical cream can lead to drug toxicity. A warm room will increase the child’s skin temperature and make itching worse. Warm milk will have no effect on itching.
The client should discuss the request for a living will with the physician. The client should also discuss this desire with the family. Wills should be prepared with legal counsel and should identify the executor of the estate, address distribution and use of property, and the specific plans for burial.
Keeping the side rails up prevents the disoriented client from accidentally falling out of bed. Providing the call light to the client gives access to the health care team when assistance is needed. Raising the head of the bed will not ensure safety. Keeping the over-the-bed light on may be disruptive. Limiting visitors will not ensure safety.
Subarachnoid (aneurysm) precautions include a variety of measures designed to decrease stimuli that could increase the client’s intracranial pressure. These include instituting dim lighting and reducing environmental noise and stimuli. Enemas should be avoided, but stool softeners should be provided. Straining at stool is contraindicated because it increases intracranial pressure.
Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of the eighth cranial nerve. Ototoxicity is a toxic effect of therapy with aminoglycosides and could result in permanent hearing loss. The nurse should hold the dose and notify the physician. Tobramycin (Tobrex)
Amiodarone (Cordarone) is an antidysrhythmic used to treat life-threatening ventricular dysrhythmias. The client should have continuous cardiac monitoring in place, and the medication should be infused by intravenous pump.
The client should discuss the living will with the physician, and it should be reviewed annually to ensure that it contains the client’s present wishes and desires.
Contact precautions include standard precautions and the use of barrier precautions such as gloves and impermeable gowns. Contact precautions are used for clients with diarrhea, draining wounds not contained by a sterile dressing, or who have acquired antibiotic-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through an intermediary infected object or surface that has been in contact with the client, such as instruments, linens, or dressing materials. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Airborne and droplet precautions are used if the organism is transmitted via the respiratory tract.
The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available.
Pentamidine (Pentam-300) can cause severe and sudden hypotension, even with administration of a single dose. The client should be lying down during administration of this medication. The blood pressure is monitored frequently during administration.
Hydralazine (Apresoline) is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse should be monitored frequently after administration, so a noninvasive blood pressure cuff is the item to have in place.
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