Accupril is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. If nausea occurs, the client should be instructed to take a noncola carbonated beverage and salted crackers or dry toast. A full therapeutic effect may be noted in 1 to 2 weeks.
Safety during defibrillation is essential for preventing injury to the client and to the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of “all clear.” For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client’s chest.
Quinidine (Quinidex) is an antidysrhythmic. Verapamil (Calan) is generally used to control heart rate. Nifedipine (Procardia) is a vasodilator. Bretylium (Bretylol) is generally used for control of ventricular dysrhythmia.
The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client’s skin, not over a gown or clothing.
For the client with VT who becomes pulseless, the physician or qualified advanced cardiac life support (ACLS) personnel immediately defibrillates the client. In the absence of this equipment, cardiopulmonary resuscitation (CPR) is initiated immediately.
Complications after insertion of an IVC filter are rare. When they do occur, they include air embolism, improper placement, and filter migration. The percutaneous approach uses local anesthesia. There is usually no need for anticoagulant therapy after surgery. Venous congestion can occur from accumulation of thrombi on the filter, but the process usually occurs gradually.
Mitten restraints are useful for this client because the client cannot pull against them, creating resistance that could lead to increased intracranial pressure (ICP). Wrist restraints cause resistance. Vest and waist restraints prevent the client from getting up or falling out of bed but do nothing to limit hand movement.
After three unsuccessful defibrillation attempts, CPR should be done for 1 minute, followed by three more shocks, each delivered at 360 joules.
Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client’s mouth. An airway should be selected that is an appropriate size. The client should be positioned supine, with the neck hyperextended if possible. The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client’s teeth. Following insertion, the client’s mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
The nurse is responsible for monitoring the client’s respiratory status and blood pressure while the client is being treated with an IV bolus of lidocaine hydrochloride.
A child with a head injury is at risk for increased intracranial pressure (ICP). Sitting up will decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist in accurate evaluation of any cerebral edema that is present and will detect early coma. Neurological assessments need to be performed to monitor for increased ICP. Forcing fluids may cause fluid overload and increased ICP. Additionally, the nurse would not “force” the client to do something.
Biofeedback, progressive muscle relaxation, meditation, and guided imagery are techniques that the nurse can teach the client to reduce the physical impact of stress on the body and promote a feeling of self-control for the client. Biofeedback entails electronic equipment, whereas the others require no adjuncts, such as tapes, once the technique is learned. Confrontation is a communication technique, not a stress-management technique. It may also exacerbate stress, at least in the short term, rather than alleviate it.
Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse may be unable to hear bowel sounds at all. When perforation occurs, the pulse will more likely be weak and rapid. Positive guaiac stool results indicate the presence of bleeding but are not necessarily indicative of perforation.
Human albumin (Albuminar) is classified as a blood derivative and is contraindicated in severe anemia, cardiac failure, history of allergic reaction, renal insufficiency, and when no albumin deficiency is present. It is used with caution in clients with low cardiac reserve, pulmonary disease, or hepatic or renal failure.
PVCs are considered dangerous when they are frequent (more than six per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave.
The term “involution” is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its nonpregnant state. Immediately following the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one fingerbreadth on each succeeding day.
The normal Po2 level is 80 to 100 mm Hg.
Giving the client with emphysema a high flow of oxygen would halt the hypoxic drive and cause apnea.
A common, life-threatening opportunistic infection that attacks clients with AIDS is Pneumocystis carinii pneumonia. Its symptoms include fever, exertional dyspnea, and nonproductive cough. The absence of respiratory distress is one of the goals that the nurse sets as a priority.
According to category-specific (respiratory) isolation precautions, a client with TB requires a private room. The room needs to be well-ventilated and should have at least six exchanges of fresh air per hour and should be ventilated to the outside
Learning depends on two things: physical and emotional readiness to learn. Without one or the other, teaching can occur, but learning may not take place. There is usually a time at which the client will indicate an interest in learning.
Breath sounds are the best way to assess for the onset of congestive heart failure. The presence of crackles or rales or an increase in crackles is an indicator of fluid in the lungs caused by congestive heart failure.
Fludrocortisone acetate (Florinef) is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity that is used for long-term management of Addison’s disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. The client can rapidly develop hypotension and fluid and electrolyte imbalance if the medication is discontinued abruptly. The medication does not affect the immune response or thyroid or thyrotropin production.
The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively.
The nurse is careful to question the surgeon about whether warfarin should be administered in the preoperative period before insertion of an IVC filter. This medication is often withheld for a period of time preoperatively to minimize the risk of hemorrhage during surgery.
Intermittent claudication is a symptom characterized by a sudden onset of leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.
Treatment for DVT may require bed rest, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements ordered once per shift or once per day, but they would not be obtained hourly.
The purpose of a serum digoxin (Lanoxin) level is to record the serum concentration of the medication to ensure that it is in the therapeutic range. Serum digoxin levels are most often drawn before a dose, although they may be drawn 4 to 10 hours after a dose was administered. Drawing the medication before a dose ensures that the level is not falsely elevated.
There should be no open flames or smoking within 10 feet of the oxygen source. The tank should remain secured in its holder, and the concentrator should be away from walls or other close quarters (to allow adequate air circulation around the unit). The oxygen source should also be removed from sources of heat or sunlight. A “no smoking” sign should be in visible view, such as in the window near the door of the client’s home.
After suctioning a client either with or without an artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions.
Aluminum hydroxide tablets should be chewed thoroughly before swallowing. This prevents them from entering the small intestine undissolved. They should not be swallowed whole. Antacids should be taken at least 2 hours apart from other medications to prevent interactive effects. Constipation is a side effect of the use of aluminum products, but the client should not take a laxative with each dose. This promotes laxative abuse. The client should first try other means to prevent constipation.
Auranofin (Ridaura) is a gold preparation that is used as an antirheumatic. Gold toxicity is an adverse effect and is evidenced by decreased hemoglobin, leukopenia, reduced granulocyte counts, proteinuria, hematuria, stomatitis, glomerulonephritis, nephrotic syndrome, or cholestatic jaundice. Anorexia, nausea, and diarrhea are frequent side effects of the medication.
Induration of 15 mm or more is considered positive for clients in low-risk groups. More than 5 mm of induration is considered a positive result for clients with known or suspected human immunodeficiency virus infection, intravenous drug users, people in close contact with a known case of tuberculosis, and the client with a chest x-ray suggestive of previous tuberculosis. More than 10 mm of induration is considered positive in all other high-risk groups.
The Allen test is performed before drawing ABGs. Each of the radial and ulnar arteries is occluded in turn and then released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation, and that site may be used. Homans' sign tests for deep vein thrombosis with dorsiflexion of the foot. Brudzinski’s sign tests for nuchal rigidity by bending the head down toward the chest. The Babinski reflex is checked by stroking upward on the sole of the foot.
Benzonatate (Tessalon) is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex.
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