ATI redem. (130)

Coping: Evaluating Ego-Defense Mechanisms of a Client Nursing Care (pt1)

Be empathetic in communication, and encourage the client to verbalize feelings. Identify the client's and family's strengths and abilities. Identify available community resources, and refer the client for counseling if needed.

Coping: Evaluating Ego-Defense Mechanisms of a Client Nursing Care (pt2)

Encourage the client's autonomy with decision-making. Encourage the client to describe coping skills used effectively in the past. Discuss the client's and family's abilities to deal with the current situation.

Older Adults (65 years and Older): Reducing the Risk for Osteoporosis

Encourage weight baring exercise(at least 30 min/3x a week) Consume adequate amount of calcium and vitamin D Spend time outdoors to increase body's production of vitamin D Excess caffiene consumption causes excretion of Ca in urine

Steps for performing an abdominal assessment: Auscultation Friction rubs Technique

Listen with the diaphragm over the liver and spleen. Ask the client to take a deep breath while you listen for any grating sounds (like sandpaper rubbing together)

Steps for performing an abdominal assessment: Auscultation Bowel sounds Unexpected sounds

Loud, growling sounds (borborygmi) are hyperactive sounds and indicate increased gastrointestinal motility. Causes diarrhea, anxiety, bowel inflammation, and reactions to some foods.

Mobility and Immobility: Using a Wheelchair for Client Transfer Assessment (pt1)

Assess ROM capability. Assess muscle tone and mass. Observe for contractures.

Nutrition and Oral Hydration: Reviewing the Medical Record of a Client Who Is Receiving Parenteral Nutrition

Assess for presence or history of nutritional deficits. Obtain lab results (total protein/albumin levels, CBC, electrolytes, BUN/creatinine, lipid profile, and serum iron levels) Monitor vital signs and observe for s/s of infection. Use strict aseptic technique with IV tubing, dressing changes, and TPN solution

Antibiotics: Allergic Reactions

Allergic reaction Hypersensitivity, rash, pruritus, hives, anaphylactic shock Superinfection Secondary infection when normal flora killed by antibiotic •- Ex: C.diff: can develop again/highest wbc Organ toxicity Ear, liver, kidney

Urinary Elimination: Interventions to Promote Voiding in a Client Who Is Postoperative

Alterations in glomerular filtration rate from anesthesia/opioid analgesics, resulting in decreased urine output Lower abdominal surgery creating obstructing edema and inflammation

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Metabolic (pt1)

Altered endocrine system Decreased basal metabolic rate Decreased appetite with altered nutritional intake Decreased urinary elimination of calcium, resulting in hypercalcemia Decreased protein resulting in loss of muscle

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Neurologic/Psychosocial

Altered sensory perception Ineffective coping Changes in Emotional Status: Depression, alteration in self-concept, and anxiety Behavioral Changes: Withdrawal, altered sleep/wake pattern, hostility, inappropriate laughter, and passivity

Steps for performing an abdominal assessment: Rebound tenderness (Blumberg's sign)

An indication of irritation or inflammation somewhere in the abdominal cavity. Use the following technique in all four quadrants. Some facilities might limit this test to advanced practitioners.

Steps for performing an abdominal assessment: Rebound tenderness (Blumberg's sign) Technique

Apply firm pressure for 4 seconds with the hand at a 90° angle and with the fingers extended. After releasing the pressure, observe the client's response to see if releasing the pressure caused pain. Ask about pain and tenderness. Never palpate an abdominal mass, tender organs, or surgical incisions deeply.

Assessing for an Allergic Reaction to Antibiotics: Nurse actions (pt!)

Before administering any medications, obtain a complete medication and allergy history. Administer diphenhydramine to treat mild rashes and hives, and to decrease angioedema and urticaria. Monitor closely if a client is receiving a medication known to be highly allergenic. Provide rapid intervention including epinephrine administration for severe allergic reaction. Notify the Rapid Response team if anaphylaxis is suspected.

Fluid Imbalances: Monitoring Labs Postoperatively (pt2)

Blood sodium Dehydration: Increased hemoconcentration (greater than 145 mEq/L) BUN: Increased (greater 25 mg/dL) due to hemoconcentration Dehydration: Increased protein, electrolytes, glucose

Client Safety: Teaching About Home Safety (pt1)

Collaborate with client, family, and members of the interprofessional team to promote client safety Complete a fall risk assessment for each client Complete a nursing history, physical examination, and home hazard appraisal Provide assistive devices and safety equipment

Older Adults (65 years and Older): Reducing the Risk for Osteoporosis Nurse actions

Consume adequate amounts of protein, Mg, vitamin K. Avoid alippery surfaces and wear rubber-bottomed shoes Exercise: reduces the risk for vertebral fractures instruct family and client regarding Ca rich food sources

Coping: Evaluating Ego-Defense Mechanisms of a Client (pt1)

Coping describes how an individual deals with problems and issues. It is the behavioral and cognitive efforts of an individual to manage stress. Factors influencing an individual's ability to cope include the number, duration, and intensity of stressors; the individual's past experiences; the current support system; and available resources..

Coping: Evaluating Ego-Defense Mechanisms of a Client (pt2)

Coping strategies are unique to an individual and can vary greatly with each stressor. Ego defense mechanisms: assist a person during a stressful situation or crisis by regulating emotional distress

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Cardiovascular (pt2)

Decreased cardiac output, leading to poor cardiac effectiveness, which results in increased cardiac workload Increased oxygenation requirement Increased risk of thrombus development

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Musculoskeletal

Decreased muscle endurance, strength, and mass (atrophy of muscles) Decreased stability (impaired balance) Altered joint mobility Altered calcium metabolism

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Gastrointestinal

Decreased peristalsis Decreased fluid intake Constipation, increasing the risk for fecal impaction

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Respiratory

Decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange Stasis of secretions and decreased and weakened respiratory muscles, resulting in atelectasis and hypostatic pneumonia Decreased cough response

Steps for performing an abdominal assessment: Inspection Assess the Skin for (pt2)

Dilated veins: An unexpected finding possibly reflecting cirrhosis or inferior vena cava obstruction Jaundice, cyanosis, or ascites: Possibly reflecting cirrhosis

Pain Management: Nonpharmacological Methods for Pain Relief (pt2)

Distraction Includes ambulation, deep breathing, visitors, television, games, prayer, and music. Decreased attention to the presence of pain can decrease perceived pain level. Relaxation: Includes meditation, yoga, and progressive muscle relaxation Imagery Focusing on a pleasant thought to divert focus Requires an ability to concentrate Acupuncture and acupressure: Stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure) Reduction of pain stimuli in the environment Elevation of edematous extremities to promote venous return and decrease swelling

Steps for performing an abdominal assessment: Health History Questions to Ask (pt1)

Do you ever have nausea, vomiting, or cramping? Have you had any change in your appetite? Do you have any food intolerances? Any recent weight changes? Do you have any difficulty with swallowing, belching or gas? Have you had any vomit containing blood? What problems, if any, do you have with your bowels? When was your last bowel movement? Do you often use laxatives or enemas? Have you had any black or tarry stools?

Steps for performing an abdominal assessment: Health History Questions to Ask (pt2)

Do you take aspirin or ibuprofen? If so, how often? Do you ever have heartburn? When? How often? Do you take medications to treat it? Have you had any low abdominal or back pain? Any tenderness in these areas? Have you had any abdominal surgery, injuries, or diagnostic tests in this area? Has anyone in your family had colon cancer? For clients over 50 years of age: Do you have routine colonoscopies? Are you aware of changes that could indicate colon cancer? Do you drink alcohol? If so, how much? What do you eat and drink on a typical day? For clients who are pregnant, when was your last menstrual period?

Pain Management: Nonpharmacological Methods for Pain Relief (pt1)

Ensure bed linens are clean and smooth, and that the client is not lying on tubing or other equipment that could cause discomfort. Position the client in anatomic position, using gentle positioning techniques, and reposition frequently to minimize discomfort. Instruct clients on the use of strategies to reduce pain. Cognitive-behavioral measures: changing the way a client perceives pain, and physical approaches to improve comfort Cutaneous (skin) stimulation: transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, and massage: Interruption of pain pathways Cold for inflammation Heat to increase blood flow and to reduce stiffness

Preoperative Nursing Care: Findings Requiring Follow-Up Prior to Surgery (pt2)

Ensure that jewelry, dentures, prosthetics, makeup, nail polish, and glasses are removed. These items can be given to the family or stored safely. Cover the client with a lightweight cotton blanket heated in a warmer to prevent hypothermia. Hypothermia increases the chance for surgical wound infections, alters metabolism of medication, and causes coagulation problems and cardiac dysrhythmias. Establish IV access using a large-bore (18-gauge) catheter for easier infusing of IV fluids or blood products. Administer preoperative medications (prophylactic antimicrobials, antiemetics, sedatives) as prescribed. Prophylactic antibiotics are administered within 1 hr of surgical incision. If the client previously took a beta-blocker, administer a beta-blocker prior to surgery to prevent a cardiac event and mortality. Have the client void prior to administration. Monitor response to medications Raise side rails following administration to prevent injury.

Client Safety: Teaching About Home Safety (pt2)

Ensure that lighting is adequate inside and outside the home Keep emergency numbers near the phone for prompt use in event of emergency Review oxygen safety measures Keep floor clean, dry, clutter-free Remove items that could cause client to trip (throw rugs) Nonskid bathmats and/or chairs for use in shower

Preoperative Nursing Care: Findings Requiring Follow-Up Prior to Surgery (pt3)

Ensure that the preoperative checklist is complete. Confirm and verify the correct surgical site with the client and all health care team members before clearly marking the surgical site. Minimize client anxiety while waiting to go to surgery by using distraction techniques (watching TV, reading, listening to music). For clients encountering severe anxiety and panic, reassurance will be necessary and sedation medications can be given. Nonpharmacological interventions (distraction, imagery, and music therapy) can be initiated. Ensure that measures are taken to prevent postoperative deep-vein thromboembolism by continuing anticoagulation therapy and/or anti-embolism stockings, pneumatic compression devices, and range-of-motion exercises.

Steps for performing an abdominal assessment: Percussion (pt1)

Expect: To hear tympany over most of the abdomen. A lower pitch tympany over the gastric bubble in the left upper quadrant is common. Dullness over the liver or a distended bladder.

Middle Adults (35 to 65 Years): Identifying a Client's Risk for Osteoporosis

Family hx Females at higher risk Lean body build Limiting protein intake Excess caffeine Tobacco use Immunizations

Steps for performing an abdominal assessment: Inspection Shape or Contour

Flat: In a horizontal line from the xiphoid process to the symphysis pubis Convex: Rounded Concave: A sunken appearance Distended: A large protrusion of the abdomen due to fat, fluid, or flatus. Measure the abdomen at the umbilicus to monitor for changes in clients who have fluid retention.

Legal Responsibilities: Completing an Informed Consent Document Client

Gives informed consent. To give informed consent, the client must: Give it voluntarily (no coercion involved). Be competent and of legal age or be an emancipated minor. When the client is unable to provide consent, another authorized person must give consent. Receive enough information to make a decision based on an understanding of what to expect.

Complementary and Alternative Therapies: Discussing Alternative Treatments With a Client (pt1)

Guided imagery/visualization therapy: Encourages healing and relaxation of the body by having the mind focus on images Healing intention: Uses caring, compassion, and empathy in the context of prayer to facilitate healing Breath work: Reduces stress and increases relaxation through various breathing patterns Humor: Reduces tension and improves mood to foster coping Meditation: Focuses attention to a single or unchanging stimulus to become more mindful or aware of self

Fluid Imbalances: Monitoring Labs Postoperatively (pt1)

Hct: Increased in both hypovolemia and dehydration unless the fluid volume deficit is due to hemorrhage Blood osmolarity Dehydration: Increased hemoconcentration osmolarity (greater than 295 mOsm/kg) Urine specific gravity Dehydration: Increased concentration (urine specific gravity greater than 1.030)

Steps for performing an abdominal assessment: Auscultation Bowel sounds Expected sounds

High-pitched clicks and gurgles 5 to 35 times/min. To make the determination of absent bowel sounds, you must hear no sounds after listening for a full 5 min.

Bowel Elimination: Discharge Teaching About Ostomy Care (pt1)

If a wound ostomy continence nurse is not available, educate the client about stoma care. Perform hand hygiene. Put on gloves. Remove the pouch from the stoma. Inspect the stoma. It should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy.

Nursing action: CAM (pt2)

Incorporate complementary or alternative therapies into clients' care plans. Evaluate client's responses to CAM interventions. Assist with evaluating the safety of herbal and natural products the client can be using. Provide the client with reliable information and determine possible interactions with prescription medicines and therapies.

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Integumentary

Increased pressure on skin, which is aggravated by metabolic changes Decreased circulation to tissue, causing ischemia, which can lead to pressure

Steps for performing an abdominal assessment: Inspection Assess the Skin for (pt1)

Lesions: Bruising, rashes, or other primary lesions Scars: Location and length Silver striae or stretch marks (expected findings)

Steps for performing an abdominal assessment: Auscultation Bowel sounds Technique

Listen with the diaphragm of the stethoscope in all four quadrants.

Mobility and Immobility: Using a Wheelchair for Client Transfer Nurse actions

Make sure clients change position in bed at least every 2 hr, and perform weight shifts in the wheelchair every 15 mins. Encourage active or provide passive ROM two or three times/day. A continuous passive motion (CPM) device might be prescribed. Develop an individualized program for each client. Older adult clients can require a program that addresses the aging process. Cluster care to promote a proper sleep-wake cycle. Request physical therapy for clients who have decreased mobility. Assist client with ambulation. Use assistive devices (gait belts, walkers, canes, or crutches) as needed.

Mobility and Immobility: Using a Wheelchair for Client Transfer Assessment (pt2)

Monitor gait. Monitor nutritional intake of calcium. Monitor use of assistive devices to assist with ADLs.

Fluid Imbalances: Caring for a Client Who Is Receiving IV Fluids (pt1)

Monitor respiratory rate, effort, and oxygen saturation (SaO2). Check urinalysis, CBC, and electrolytes. Administer supplemental oxygen as prescribed. Measure the client's weight daily at same time of day using the same scale. Observe for nausea and vomiting. Assess heart rhythm. Assess postural blood pressure and pulse. (Check for hypotension and orthostatic hypotension.) Check neurologic status to determine level of consciousness. Initiate and maintain IV access.

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Metabolic (pt2)

Negative nitrogen balance Loss of weight Alterations in calcium, fluid, and electrolytes Resorption of calcium from bones Changes in protein, carbohydrate, and fat metabolism

Pressure Injury, Wounds, and Wound Management: Evaluating Performance of a Wound Irrigation Procedure (pt2)

Never use the same gauze to cleanse across an incision or wound more than once. Do not use cotton balls and other products that shed fibers. If irrigating, use a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5 to 8 psi of pressure. A 30 to 60 mL syringe with a 19-gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer's, or an antibiotic/antimicrobial solution. Hold the tip 2.5 cm (1 in) above the wound. Use continuous pressure to flush the wound, repeating the procedure until the irrigant flowing out of the wound is clear.

Steps for performing an abdominal assessment: Inspection

Note any guarding or splinting of the abdomen Inspect the umbilicus for position, shape, color, inflammation, discharge, and masses

Nursing Process: Priority Action Following a Missed Provider Prescription

Notify provider and collaborate to produce new care plan/fill out a report Educate them on the missed prescription and what will happen

Fluid and Electrolyte Imbalances: Expected Findings for a Client Who Has Hypocalcemia (pt2)

Numbness, tingling of fingers, toes, and circumoral region Positive Trousseau/Chvostek sign Seizures Carpopedal spasms Bronchospasm Hyperactive deep tendon reflexes

Steps for performing an abdominal assessment: Inspection Shape or Contour (pt2) -Distended

Obese: The client has rolls of adipose tissue along both sides, and the skin does not look taut. Fluid: The flanks also protrude, and when the client turns onto one side, the protrusion moves to the dependent side. Flatus: The protrusion is mainly midline, and there is no change in the flanks. Hernias: Protrusions through the abdominal muscle wall are visible, especially when the client flexes the abdominal muscles.

Legal Responsibilities: Completing an Informed Consent Document Provider

Obtains informed consent. To do so, the provider must give the client The purpose of the procedure: A complete description of the procedure. A description of the professionals who will perform and participate in the procedure. A description of the potential harm, pain, or discomfort that might occur. Options for other treatments. The option to refuse treatment and the consequences of doing so.

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Cardiovascular (pt1)

Orthostatic hypotension Less fluid volume in the circulatory system Stasis of blood in the legs Diminished autonomic response

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Musculoskeletal (pt2)

Osteoporosis Pathological fractures Contractures Foot drop

Steps for performing an abdominal assessment: Palpation

Palpate tender areas last.

Mobility and Immobility: Using a Wheelchair for Client Transfer Client Education

Perform ROM while bathing, eating, grooming, and dressing. Maintain good posture

Mobility and Immobility: Application of Antiembolic Stockings (pt1)

Perform hand hygiene. Assess skin, circulation, and presence of edema in the legs. Measure the calf and/or thigh circumference and the length of the leg to select the correct size stockings. Turn the stockings inside to the heel. Put the stockings on the feet. Pull the remainder of the stockings over the heels and up the legs.

Pressure Injury, Wounds, and Wound Management: Evaluating Performance of a Wound Irrigation Procedure (pt1)

Perform wound cleansing and irrigation.For clean wounds (a surgical incision), cleanse from the least contaminated (the incision) toward the most contaminated (the surrounding skin). Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound. Although the provider might prescribe other mild cleansing agents, isotonic solutions remain the preferred cleansing agents.

Steps for performing an abdominal assessment: Inspection Movement of the Abdominal Wall

Peristalsis: Wavelike movements visible in thin adults or in clients who have intestinal obstructions. Pulsations: Regular beats of movement midline above the umbilicus are expected findings in thin adults, but a pulsating mass is unexpected.

Fluid Imbalances: Caring for a Client Who Is Receiving IV Fluids (pt2)

Provide oral and IV rehydration therapy as prescribed. Monitor I&O. Encourage fluids as tolerated. Alert the provider to a urine output less than 30 mL/hr. Monitor level of consciousness and ensure client safety. Observe level of gait stability. Encourage the client to use the call light and ask for assistance. Encourage the client to change positions slowly (rolling from side to side or standing up).

Safe Medication Administration and Error Reduction: Comparing the Medication Administration Record to the Medication Container

Read medication labels and compare them with the MAR three times: before removing the container when removing the amount of medication from the container the presence of the client before administering the medication. Leave unit-dose medication in its package until administration.

Assessing for an Allergic Reaction to Antibiotics: Nurse actions (pt2)

Remove or prevent further exposure to the allergen. Treat anaphylaxis with epinephrine, bronchodilators, and antihistamines. Provide respiratory support and notify the provider . Monitor ABGs and administer inhaled beta-adrenergic agonists (albuterol). The client can require intubation or a tracheostomy for severe manifestations. Monitor hemodynamic status. The client usually experiences extensive vasodilation and capillary leak (tachycardia, weak pulse). Monitor the client frequently, as manifestations can recur as treatment wears off.​​​​​​​

Steps for performing an abdominal assessment: Auscultation Bowel sounds

Result from the movement of air and fluid in the intestines. The most appropriate time to auscultate bowel sounds is in between meals.

Expected Changes with Aging; Abdomen (pt2)

Saliva, gastric secretions, and pancreatic enzymes decrease. Esophageal peristalsis and small-intestine motility decrease

Complementary and Alternative Therapies: Discussing Alternative Treatments With a Client (pt2)

Simple touch: Communicates presence, appreciation, and acceptance Music or art therapy: Provides distraction from pain and allows the client to express emotions; earphones improve concentration Therapeutic communication: Allows clients to verbalize and become aware of emotions and fears in a safe, nonjudgmental environment Relaxation techniques: Promotes relaxation using breathing techniques while thinking peaceful thoughts (passive relaxation) or while tensing and relaxing specific muscle groups (progressive relaxation)

Mobility and Immobility: Application of Antiembolic Stockings (pt2)

Smooth any creases or wrinkles. Remove the stockings every 8 hr to assess for redness, warmth, or tenderness. Make sure the stockings are not too tight over the toes. Keep the stockings clean and dry. Clients who are postoperative or have specific needs may need a second pair of hose. Document the application and removal of the stockings

Client Safety: Nursing Action When a Client Falls During a seizure

Stay with the client, and call for help. Maintain airway patency and suction PRN. QS​​​​​​​ Administer medications. Note the duration of the seizure and the sequence and type of movements. After a seizure, determine mental status and measure oxygenation saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery. Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider.

Steps for performing an abdominal assessment: Equipment

Stethoscope Tape measure or ruler Marking pen

Steps for performing an abdominal assessment: Percussion (pt2)

The liver span is a measurement of liver size at the right midclavicular line. The expected finding is 6 to 12 cm (2.4 to 4.7 in). Findings outside this range indicate hepatomegaly. Assess for kidney tenderness by fist percussion over the costovertebral angles at the scapular lines on the back. The expected finding is no tenderness.

Steps for performing an abdominal assessment

This examination includes observing the shape of the abdomen, palpating for masses, and auscultating for vascular sounds. Use the techniques of inspection, auscultation, percussion, and palpation. Note that this changes the usual order of assessment techniques. Auscultate just after inspection because percussion and palpation can alter bowel sounds. Ask the client to urinate before the abdominal examination. Have the client lie supine with arms at both sides and knees slightly bent.

Steps for performing an abdominal assessment: Palpation Deeper

Two-handed approach: The top hand depresses the bottom hand 2.5 to 7.5 cm (1 to 3 in) in depth. The bottom hand assesses for organ enlargement or masses. Expected findings: The stool can be palpable in the descending colon.

Nursing action: CAM (pt1)

Understand the varieties of therapies available and any safety precautions associated with their use. Be receptive to learning about clients' alternative health beliefs and practices (home remedies, cultural practices, vitamin use, modification of prescriptions). Identify clients' needs for complementary or alternative therapies, along with the client's values and treatment preferences.

Mobility and Immobility: Priority Finding for a Client Who Is Immobile Genitourinary

Urinary stasis Change in calcium metabolism with hypercalcemia, resulting in renal calculi Decreased fluid intake and increased use of indwelling urinary catheters, resulting in urinary tract infections

Client Safety: Nursing Action When a Client Falls Nurse actions (pt2)

Use current evidence to promote a culture of safety, while using the National Patient Safety Goals as a guide. Know the facility's disaster plan, understand the chain of command and roles, and use common terminology when communicating with the team. Identify and document incidents and responses according to the facility's policy. These reports help identify trends, patterns, and the root cause of adverse events. QS Know the location of safety data sheets and hazardous chemicals in the environment. Use equipment only after adequate instruction and safety inspection.

Bowel Elimination: Discharge Teaching About Ostomy Care (pt2)

Use mild soap and water to cleanse the skin, then dry it gently and completely. Moisturizing soaps can interfere with adherence of the pouch. Apply paste if necessary. Measure and mark the desired size for the skin barrier. Cut the opening 0.15 to 0.3 cm (1⁄18 to 1⁄8 in) larger, allowing only the stoma to appear through the opening. If necessary, apply barrier pastes to creases. Apply the skin barrier and pouch. Fold the bottom of the pouch and place the closure clamp on the pouch. Dispose of the used pouch. Remove the gloves and perform hand hygiene.

Client Safety: Nursing Action When a Client Falls Nurse actions (pt1)

Use risk assessment tools to evaluate clients and their environment for safety Encourage clients to speak up and take an active role in their health care and in preventing errors. Create a culture of checks and balances to avoid errors when working in stressful circumstances. Communicate risk factors and plans of care to clients, family, and other staff. Use protocols for responding to dangerous situations. Adopt quality care priorities from the National Quality Forum, including "Never Events."

Steps for performing an abdominal assessment: Palpation Light

Use the finger pads on one hand to palpate to a depth of 1.3 cm (0.5 in) in each quadrant. Expect softness, no nodules, and no guarding. The bladder is palpable if full; otherwise, it is nonpalpable

Preoperative Nursing Care: Findings Requiring Follow-Up Prior to Surgery (pt1)

Verify that the informed consent is accurately completed, signed, and witnessed. Administer enemas and/or laxatives the night before and/or the morning of the surgery for clients undergoing bowel surgery. Regularly check scheduled medication prescriptions. Some medications (antihypertensives, anticoagulants, antidepressants) can be withheld until after the procedure. Withhold anticoagulants at least 48 hrs before surgery. Determine whether autologous blood or direct blood donation from family is available if needed. Ensure that the client remains NPO for at least 6 hr for solid foods and 2 hr for clear liquids before surgery with general anesthesia to avoid aspiration. Note on the chart the last time the client ate or drank. Perform skin preparation, which can include cleansing with antimicrobial soap. If absolutely necessary, use electric clippers or chemical depilatories to remove hair in areas that will be involved in the surgery.

Expected Changes with Aging; Abdomen (pt1)

Weaker abdominal muscles declining in tone and more adipose tissue result in a rounder, more protruding abdomen. Peritoneal inflammation is more difficult to detect due to less pain, guarding, fever, and rebound tenderness.

Legal Responsibilities: Completing an Informed Consent Document Nurse

Witnesses informed consent.​​​​​​​ This means the nurse must: Ensure that the provider gave the client the necessary information. Ensure that the client understood the information and is competent to give informed consent. Have the client sign the informed consent document. Notify the provider if the client has more questions or appears not to understand any of the information. The provider is then responsible for giving clarification. Document questions the client has, notification of the provider, reinforcement of teaching, and use of an interpreter.

Steps for performing an abdominal assessment: Auscultation Friction rubs

result from the rubbing together of inflamed layers of the peritoneum.

Fluid and Electrolyte Imbalances: Expected Findings for a Client Who Has Hypocalcemia (pt1)

↓ BP Anxiety Irritability Diarrhea Impaired clotting time/↓ prothrombin ECG: prolonged QT interval and lengthened ST Labs indicate: ↓ Mg++