Immediately following laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential life-threatening situation, and the surgeon is notified to further evaluate the client and suture or repair the bleed.
Early ambulation should not exceed the client’s tolerance. The client should be assessed before sitting. The client is assisted to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client’s side to provide physical support and encouragement.
Storing a stool specimen for culture in a refrigerator is contraindicated because it can retard the growth of organisms. A stool specimen is obtained using sterile gloves and a sterile container. After obtaining the specimen, the stool is sent immediately to the laboratory.
Following spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer board and the assistance of four people. This permits optimal stabilization and support of the spine, while allowing the client to be moved smoothly and gently.
The catheter’s balloon is behind the opening at the insertion tip. The catheter is inserted 2.5 to 5 cm after urine begins to flow in order to provide sufficient space to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could produce trauma.
In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client’s primary drive for breathing. If oxygen is given too freely, the client loses the respiratory drive, and respiratory failure results. Thus, the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute.
Following thyroidectomy, respiratory distress can occur from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and suction equipment readily available and in working order if such an emergency were to arise. Apnea is not a problem associated with thyroidectomy, unless the client experienced a respiratory arrest.
The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client.
The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. While adaptation, diversion, and consistency are important, protection from injury is the highest priority.
Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse has a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops.
Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a facemask for both the nurse and client are extremely important. It is also imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and an apron. The connection site should not be covered and it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.
To perform suctioning, the nurse hyperoxygenates the client using a manual resuscitation bag or the sigh mechanism if the client is on a mechanical ventilator. The safe suction range for an adult is 100 to 120 mm Hg. The nurse advances the suction catheter into the tracheostomy without occluding the Y-port; suction is never applied while introducing the catheter because it would traumatize mucosa and remove oxygen from the respiratory tract. The nurse uses intermittent suction in the airway for up to 10 to 15 seconds.
MVGA is a radionuclide study used to detect myocardial infarction, decreased myocardial blood flow, and left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary. The procedure does not use radiopaque dye. Therefore, allergies to iodine and shellfish is not a concern. A Foley catheter and CVP line are not required.
Clients who have Alzheimer’s disease have significant cognitive impairment and are therefore at risk for injury. It is critical for the nurse to maintain a safe environment, particularly as the client’s judgment becomes increasingly impaired.
Major depression, recurrent, with psychotic behaviors alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one must also deal with a client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with life’s demands. Disturbed thought processes generally indicates a state of increased anxiety in which hallucinations and delusions prevail.
The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation.
After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours following a treatment. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use
Chlamydia is a sexually transmitted disease and is frequently called nongonococcal urethritis in the male client. It requires no special precautions other than standard precautions. Caregivers cannot acquire the disease during administration of care, and standard precautions are the only measure that needs to be used.
The client who receives a narcotic analgesic should immediately have the side rails raised on the bed to prevent injury once the medication has taken effect.
The nurse should always inspect the vial of insulin before use for solution changes that may signify loss of potency. NPH insulin is normally uniformly cloudy. Clumping, frosting, and precipitates are signs of insulin damage. In this situation, becaues potency is questionable, it is safer to discard the vial and draw up the dose from a new vial.
Foscarnet (Foscavir) is an antiviral agent used to treat cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled infusion device. It is highly toxic to the kidneys, and serum creatinine levels are measured frequently during therapy. Folic acid is not an antidote.
A client must be alert, able to communicate, and competent to sign an informed consent. If the client is unable to, then the family can sign the consent. A living will lists the medical treatment a person chooses to omit or refuse if the person becomes unable to make decisions and is terminally ill. Advanced directives are forms of communication in which persons can give direction on how they would like to be treated when they cannot speak for themselves.
Clients known or suspected of having TB should wear a mask when out of the hospital room to prevent the spread of the infection to others.
Following administration of an intramuscular injection, the nurse would massage the site to assist in medication absorption. Then, the nurse assists the client to a comfortable position. The uncapped needle and syringe are discarded in a puncture-resistant container, gloves are removed, and the hands are washed.
Valproic acid (Depakene) is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. Otherwise, it may be given after meals to avoid gastrointestinal upset.
Sinus tachycardia is often caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise.
A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening the system.
Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, and for the same reason, the drainage tubing is not placed or looped under the client’s leg. The tubing must drain freely at all times.
Clients with preeclampsia are at risk of developing eclampsia (seizures). Bright lights and sudden loud noises may initiate seizures in this client. A woman with preeclampsia should be placed in a dimly lighted, quiet, private room. Visitors should be limited to allow for rest and prevent overstimulation. Clients with preeclampsia have decreased plasma volume, and adequate fluid and sodium intake is necessary to maintain fluid volume and tissue perfusion. Vital signs need to be monitored more frequently than every 4 hours when preeclampsia is present.
Bronchoscopy requires that informed consent be obtained from the client before the procedure. The client is kept NPO for at least 6 hours before the procedure. It is unnecessary to inquire about allergies to shellfish before this procedure, because contrast dye is not injected. There is also no need for prophylactic antibiotics.
A client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction, as well as monitoring weight and intake and output. The client may be placed on bed rest or at least encouraged to rest, because a direct correlation exists between proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.
Spinal shock is often accompanied by vasodilation in the lower limbs, which results in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse should provide for a gradual progression in head elevation while monitoring the blood pressure. A vasodilator would exacerbate the problem. Clients with cervical cord injuries cannot lock their knees, and the use of splints would impair the transfer.
The child with undiagnosed exanthema needs to be placed on strict isolation. Varicella causes a profuse rash on the trunk with a sparse rash on the extremities. The incubation period is 14 to 21 days. It is important to prevent the spread of this communicable disease by placing the child in isolation until further diagnosis and treatment is made.
In extracorporeal shock wave lithotripsy, a noninvasive procedure, the client is anesthetized (spinal or general) and placed in a water bath. Anesthesia is necessary to keep the client very still during the procedure. Shock waves are administered that shatter the stone without damaging the surrounding tissues. The stone is broken into fine sand, which is secreted into the client’s urine within a few days after the procedure. Hematuria is common after the procedure. The presence of clots in the urine needs to be reported to the physician. Clots could indicate a complication such as a hematoma.
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