Passpoint Client Needs
The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the best response by the nurse?
"I will find you a computer that is not being used so you can enter the order into the computerized order entry system." The nurse cannot give the furosemide right away because the prescription needs to be put in the computerized order entry system first. This is not an emergency. The correct response is to have the health care provider put the prescription in the computerized order entry system because it is not an emergency. Verbal orders are for emergencies only. The charge nurse does not need to know about the prescription. The charge nurse does not need to put the order in the computerized order entry system. The nurse assigned to the client is responsible for the client's care. The nurse can call the pharmacy right away to have the furosemide sent, but the prescription needs to be entered first. The pharmacy will not send the medication, because it is not an emergency, without an order first. The nurse should not put the prescription in the computerized order entry system. The health care provider needs to put the prescription in the computerized order entry system. Verbal orders are for emergencies only.
A client recently diagnosed with hyperparathyroidism demands to see what the healthcare provider has written in the chart. What is the nurse's best response?
"I'll get the chart and set up a time for you to review it with your healthcare provider." Every client has a right to access information that the hospital has collected about the client. However, it is in the client's best interests to have a knowledgeable professional present to explain complicated information and unfamiliar terminology that the chart might include. Having the client sign a release of medical information may be necessary, but that does not assist the client to schedule a review with the healthcare provider. Suggesting the client review the chart with the healthcare provider does not facilitate the review. Contacting medical records to set up a time for the client to review does not ensure that a knowledgeable professional is available to assist the client during the review.
The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client becomes upset when the health care provider (HCP) persists in asking about alcohol intake. What should the nurse tell the client about the reason for these questions?
"There is a strong link between alcohol use and acute pancreatitis." Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.
A client was diagnosed with chronic gouty arthritis 2 years ago. The client has been taking sulfinpyrazone, 200 mg P.O. b.i.d. as maintenance therapy. How soon after administration of this drug does onset of action occur?
30 minutes Sulfinpyrazone has a rapid onset of action, within 30 minutes after oral administration. It reaches its peak concentration within 1 to 2 hours and has a duration of action of 4 to 6 hours.
A nurse has been assigned to four clients. Which client should the nurse see first?
A client with hemophilia who is receiving acetylsalicylic acid (ASA) for joint pain A client with hemophilia should be seen first because ASA will increase bleeding. It should not be given to a client with hemophilia. Malar rash or "butterfly" rash is usually seen in clients with SLE. Adalimumab is a tumor necrosis factor (TNF) inhibiting anti-inflammatory drug given to clients with rheumatoid arthritis. A client with Hodgkin's lymphoma is expected to have fatigue and night sweats.
Which statement by the parent of a toddler most suggests that the child is at risk for iron-deficiency anemia?
"He drinks over four glasses of milk per day." Milk is a poor source of iron. Toddlers should have between two and three servings of milk per day. Iron-deficiency anemia can be caused when excessive milk intake of more than 32 oz (1 liter)/day intake displaces iron-rich food in the diet. While 6 oz (300 mL) is the recommended daily limit for apple juice, it does contain more iron than milk. Food preferences vary among children. It is acceptable for the child to refuse foods as long as the diet is balanced and contains adequate calories.
Following a client's total hip replacement, what should the nurse do? Select all that apply.
Encourage the client to use the overhead trapeze to assist with position changes. Use a fracture bedpan when needed by the client. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.
While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots indicate which condition?
Epstein's pearls For the initial management of nosebleed, the client should sit up and lean forward with the head tipped downward. The soft tissues of the nose should be compressed against the septum with the fingers. The head-back position allows blood to flow down the throat, putting the client at risk for aspiration and allowing blood to enter the gastrointestinal tract, which can trigger vomiting.
A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan?
Follow the formal written plan of action for coordinating the response of the hospital staff. When a disaster occurs, a formal written plan of action is put into place. All nurses will follow the formal plan of action. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan will focus on having health professionals and supplies available.
A client with idiopathic thrombocytopenic purpura (ITP) is being treated with prednisone and rituximab. The nurse prioritizes what aspect of care planning?
Infection control measures In ITP, the client's immune system attacks the client's platelets, resulting in thrombocytopenia. To treat this condition, immunosuppression with medications is a common treatment. The medications, including corticosteroids such as prednisone and biologics such as rituximab, greatly increase the client's risk for infection. Protecting the client from a hospital-acquired infection is the priority because this has the potential to be a fatal complication. While the nurse should take the other actions, including monitoring platelet counts, preventing infection has the potential to have the greatest positive effect for the client's well-being.
A client has a patient a controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first?
Inspect the infusion site. The nurse should first check the infusion site to be sure the site has not infiltrated. Next, the nurse should check the PCA pump to determine if it is functioning properly. Assessing vital signs would be important to provide additional data about the possible cause of pain, but is not the first action at this time. It is not necessary to notify the health care provider (HCP) unless the infusion site or pump is malfunctioning and other methods of managing the pain are required.
Hodgkin lymphoma is a type of cancer that affects the lymphatic system resulting in excess production of lymphocytes causing swollen lymph nodes and impaired immune response.
Laboratory testing is anticipated for a client with a differential diagnosis of Hodgkin lymphoma. Due to the splenomegaly and jaundice noted on assessment, liver involvement is possible; therefore, liver function tests (LFTs), including AST and ALT levels are monitored. Imaging testing is anticpated for a client with a differential diagnosis of Hodgkin lymphoma, including the following: CT scans and an MRI. These imaging tests may reveal lymphadenopathy, hepatomegaly, splenomegaly, lung nodules or infiltrates, and pleural effusion. A lymph node biopsy confirms the presence of Reed-Sternberg cells (i.e., abnormal histiocyte proliferation, and nodular fibrosis and necrosis) which confirms the diagnosis; additionally, this diagnostic procedure lymph node and organ involvement. Bone marrow aspiration and biopsy reveals advanced disease.
A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the catheter is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age group has a need to accomplish which goal?
Protect the image of an intact body. Preschool-age children worry about having an intact body and become fearful of any threat to body integrity. Allowing the child to participate in required care helps protect her image of an intact body. Development of trust is the task typically associated with infancy. Additionally, allowing the child to apply a dressing over the intravenous insertion site is unrelated to the development of trust. Finding diversional activities is not a priority need for a child in this age group. Separation anxiety is more common in toddlers than in preschoolers.
The toddler with nephrotic syndrome exhibits generalized edema. Which measure should the nurse institute for this child with impaired skin integrity related to edema?
Separate opposing skin surfaces with soft cloth Placing soft cloth between opposing skin surfaces absorbs moisture and keeps the area dry, thus preventing any further breakdown. The child with nephrotic syndrome and severe edema is usually maintained on bed rest. Therefore, ambulation is not appropriate. Applying lotion or powder to edematous surfaces that touch increases moisture and can lead to maceration, causing further breakdown.
A pregnant client presents to the emergency department with complaints of back pain. This is the second visit in a month. She is accompanied by her spouse, who refuses to let the client speak for herself. When inspecting the painful area, the nurse notes bruising on the client's lower back. The client's spouse states that the client is clumsy and falls down the front steps of the house often. What should the nurse do first in this situation?
Separate the pregnant client from her partner. The possibility of violence should be considered when there are injuries to the client and a reported history that is not consistent with the actual presenting problems. If abuse is suspected, immediately isolate the woman from the possible abuser. The client and the fetus are assessed for safety. The fetal heart rate should be monitored, and the nurse should assess for bleeding and contractions. The nurse should ask the woman if she feels safe going home with her partner, whether she has an escape plan if she feels in danger, and if she has an immediate need for a place of safety. A list of community resources should be provided to the client whether they are needed at this time or for the future.
During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?
The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if the client goes into atrial fibrillation, but this client isn't a priority at this time.
A client with generalized anxiety disorder has told the nurse that the client wants to talk to the care provider about the possibility of taking kava. What characteristic of this client's health status should be of greatest concern to the nurse?
The client has a diagnosis of hepatitis C. Kava is associated with hepatotoxicity and would be contraindicated in a client with liver disease. Variables related to substance use, medication adherence, and nutritional status are directly affected by the possible use of kava as an antianxiety agent.
A nurse at a community mental health clinic is caring for a client diagnosed with a specific phobia of being in enclosed spaces. The client wants assistance to stop these troubling symptoms. The nurse determines which goal is the most appropriate?
The client will be able to meet social and occupational functioning in the presence of the phobic situation. The client with a phobia typically avoids the anxiety-producing stimulus. Learning to function in the presence of the stimulus will bring the client to a better level of functioning. The client is already aware of times when the phobic response occurs. Recognizing signs of escalating anxiety is not appropriate for specific phobia, because the client already knows when the symptoms will occur. Ritualistic behaviors are symptomatic of obsessive-compulsive disorders, not phobic disorders.
The nurse develops a care plan to prevent complications and promote postoperative pain control for a client returning from abdominal surgery. Which intervention meets these goals?
The nurse develops a care plan to prevent complications and promote postoperative pain control for a client returning from abdominal surgery. Which intervention meets these goals? Postoperative pain management should be implemented before pain levels rise to an intolerable level and before activities that may increase pain, such as physical therapy. Assessing pain every 4 hours would not be adequate in the early postoperative period. Analgesics should not be routinely administered without evaluation for need and effectiveness. Application of ice and splinting an abdominal incision do not provide sufficient comfort for fresh surgical pain.
Anxiety occurs in degrees, from a level that stimulates productive problem solving to a level that is severely debilitating. At a mild, productive level of anxiety, the nurse should expect to see what cognitive characteristic of mild anxiety?
accurate perceptions With mild anxiety, perceptions are accurate. Slight muscle tension reflects a motor response. Occasional irritability is an emotional response. Loss of contact with reality is a cognitive characteristic of severe anxiety.
A nurse assessing a client with catatonia notes a lack of responsiveness and ridged posturing. What is the best nursing intervention?
administer 2 mg lorazepam intramuscular injection (IM) A client with catatonia shows a lack of responsiveness to the environment. The client may move rapidly or slowly, often alternating between patterns of movement. In many cases, they pose and appear rigid. Benzodiazepines are the drugs of choice for catatonia. Clinically significant improvement typically begins to occur about 24 hours after starting benzodiazepines. Clients who are unresponsive or insufficiently responsive to benzodiazepines may require electroconvulsive therapy (ECT).
The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history?
atrial fibrillation and a mild stroke one month ago Due to the risk of bleeding, a recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy. The nurse should hold the administration of alteplase (tPA) and notify the healthcare provider. The nurse should also check the client's history for anticoagulant use, which could also result in contraindication for tPA. Having had no previous history of cardiovascular disease or having the classic risk factors such as hypertension, dyslipidemia, and peripheral artery disease would not preclude the use of tPA nor would a past history of myocardial infarction with angioplasty a year ago.
An adolescent client is having difficulty coping following the drowning death of a close friend. The client reports recurring nightmares and intrusive thoughts about the friend's death. Which assessment is most important for the nurse to make?
availability of social supports Adolescents and adults will typically have recurring nightmares and intrusive thoughts following a traumatic event. Social supports are an important factor for the nurse to assess. Social support assists the client in the recovery environment when dealing with stressful events. Although adolescents will typically experience long-term worries about their safety and security, drug use in the school is an unrelated matter that is not necessarily a risk for this client. Failing grades could be anticipated, as the psychological effects are evident in lack of concentration, easy distractibility, poor attention, and problems with memory. Isolation, withdrawal, and avoiding recollections of the traumatic event are also anticipated signs following a traumatic event. The priority assessment in this situation would be the availability of social supports to assist the client in coping with death
For the client experiencing alcohol withdrawal delirium, which healthcare provider prescriptions should the nurse question?
chlorpromazine, 100 mg PO every 4 hours PRN The nurse should question the prescription for chlorpromazine, 100 mg PO every 4 hours PRN, for agitation. Chlorpromazine is a major tranquilizer and antipsychotic that decreases the seizure threshold. During alcohol withdrawal, central nervous system irritability is present, and seizures can occur. The nurse should question this drug prescription because of the increased risk of seizure.
When auscultating a client's chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound?
closing of the aortic and pulmonic valves The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.
A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's spouse reports that the client acted confused and was extremely weak upon waking that morning. The client's blood pressure is 90/58 mm Hg, pulse is 116 beats/minute, and temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion?
hydrocortisone Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.
A client states feelings of sadness and is seeking suggestions for strategies to keep active after the loss of their spouse. Which activities might the nurse suggest to the client? Select all that apply.
joining a golf league at a club, attending regular spiritual/church services, participating in a community charity event. It is common after the loss of a spouse to experience sadness related to the grieving process and have difficulty socializing independently. Participating with other individuals in team related sports or religious activity or having a common goal at a charity event are client-directed activities which connect the client to others. Independent activities include walking and attending a movie.
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
latent phase The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes. The first stage of labor doesn't include an expulsive phase.
A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid? Select all that apply.
liver, cod, sardines. The client with gout should avoid foods that are high in purines, such as liver, cod, and sardines. Other foods to avoid include anchovies, kidneys, sweetbreads, lentils, and alcoholic beverages, especially beer and wine. Green leafy vegetables, chocolate, eggs, and whole milk are not high in purines and, therefore, not restricted in the diet of a client with gout.
The client finds the chronic tinnitus of Ménière's disease extremely irritating. The nurse should instruct the client to:
mask the tinnitus with background music. The chronic tinnitus associated with Ménière's disease can be extremely intrusive and frustrating for clients. Attempting to mask tinnitus with a low-level competing sound, such as music, is often recommended.
A coworker confides in the nurse that she had been a lifelong friend of a client who committed suicide. The coworker states: "We just saw each other last week. I can't believe she tried to kill herself. She told me she wanted to give me her expensive necklace because our friendship meant so much to her. She seemed really happy and content. I knew she had been feeling down the last few months. I should've known that something was wrong; I should've asked her about suicide." The nurse determines the coworker is most likely experiencing which condition?
moral distress Moral distress occurs when one is unable to act because of internal or external constraints. The nurse is not able to change the way she interacted with her friend the last time she saw her and is feeling anguish. Secondary traumatic stress is distress that is a result of hearing first-hand traumatic experiences of another. A boundary violation is behavior by a professional that have violated the limits of a professional-client relationship. Compassion fatigue is disengagement on the part of the care-giving professional.
After trying for a year to conceive, a couple consults an infertility specialist. When obtaining a history from the husband, the nurse asks about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility?
mumps Mumps is the childhood infectious disease that most significantly affects male fertility. Chickenpox, measles, and scarlet fever don't affect male fertility.
The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. What does the nurse determine is the family's risk of having another child with sickle cell anemia?
one chance in four for each pregnancy Sickle cell disease is an autosomal recessive Mendelian disorder. Therefore, if both parents have the trait, there is a one-in-four chance that any child (each pregnancy) will have the disease and a one-in-two chance that a child (each pregnancy) will have the trait.
The nurse is preparing a primary prevention program to reduce the incidence of osteoporosis in a population. For which risk factors will the nurse screen to identify the subgroup of the population who is at greatest risk for developing osteoporosis?
postmenopausal women who are inactive In primary osteoporosis, the rate of bone resorption accelerates while bone formation slows. Although the cause of primary osteoporosis is unknown, an important contributing factor may be faulty protein metabolism resulting from estrogen deficiency and a sedentary lifestyle and is more common in underweight, rather than overweight women. Typically, primary osteoporosis would occur in females who are postmenopausal. Although smoking does increase the risk for primary osteoporosis, this is not as significant as being postmenopausal and decreased activity level. Hyperthyroidism increases the risk for secondary osteoporosis but hypothyroidism is not a significant risk factor unless it is overtreated.
An elderly client who experiences several adverse drug reactions may benefit from
reduced drug dosages. In older clients, diminished hepatic and renal function commonly reduces drug metabolism and excretion. Because adverse reactions are frequently related to drug blood level, the client may benefit from reduced drug dosages. Adverse drug reactions don't represent a reason for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the client's body reacts to the drug.
When percussing a client's chest, what should the nurse expect to hear?
resonance Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.
The nurse is assessing a 6-month-old and notices no pincer grasp on either hand. The parent asks the nurse if this is abnormal. The nurse correctly responds that:
the 6-month-old does not normally have a pincer grasp yet. The nurse would be incorrect to inform the parent that the infant could be at risk for developmental disabilities, because the pincer grasp does not present itself until around 9 months of age. Deferring the question to the physician is ignoring the mother's concern, and the nurse can manage this question. There is no need to ask the physician about the infant's other siblings.
A 17-year-old gang member, who is living on the streets, is hospitalized after an overdose. When medically stable, the teen is admitted to the adolescent psychiatric unit of the same hospital. In what order of priority from first to last should the nurse explore the issues? All options must be used.
the current level of suicidal risk the desire to leave or remain in the gang the desire to return home or go elsewhere after discharge he reason the teen is not living with parents Safety is the first priority, followed by the client's feelings about leaving the gang. If the client chooses to remain in the gang, the other issues are moot. If the client wishes to leave the gang, the issue of living arrangements becomes significant. If the wish is to return home, it would be important to discover the reasons why the teen left the home and to explore if relationships can be repaired. If the client desires to live elsewhere, it would need to be a place safe from the gang. Foster or adoptive care is unlikely because the client is near 18 years of age.
The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to:
touch the back of the client's throat with a tongue blade. The best technique for assessing the gag reflex is to touch the back of the client's throat in the pharyngeal area with a tongue blade or cotton swab. The reflex is absent if the client does not gag. Reflexes are typically absent or sluggish in the presence of increased intracranial pressure. Swallowing does not indicate the presence of a gag reflex. It is dangerous to place liquids in the mouth of a client with an unconfirmed gag reflex because of the risk of aspiration. Endotracheal suctioning does not test the client's gag reflex.
The nurse notices a pair of nervous-acting individuals entering the emergency department. When reporting suspicious activity, the nurse should include which information in the report? Select all that apply.
vehicle's description & current location of parties involved. All suspicious individuals or activities should be reported as soon as possible to the security department. When reporting an incident, nurses/employees should provide : (a) type of incident; (b) persons involved/physical description; (c) vehicles involved and description; (d) date and time the incident occurred; (e) location where the incident occurred; (f) weapons involved; and (g) current location of parties involved. All reports of threats, actual episodes of violence, or suspicious individuals or activities must be investigated.
The parent of a 9-month-old expressed concern that the baby "is developing slowly." The nurse is concerned about a developmental delay when finding the baby is unable to accomplish which skill?
vocalizing single syllables Normally, a 9-month-old infant should have been voicing single syllables since 6 months of age. Absence of this finding would be a cause for concern. An infant usually is able to stand alone at about 10 months of age. An infant usually is able to build a tower of two cubes at about 15 months of age. An infant usually is able to drink from a cup with little spilling at about 15 months of age.
After teaching the client about lochia, the nurse determines that the client understands the instructions when she says that on the 10th or 11th postpartum day, the lochia should be which color?
white About the 10th day after childbirth, the discharge becomes thin, scanty, and almost without color (white). At this time, it is called lochia alba. The vaginal discharge from approximately day 4 through day 9 becomes more serous and watery, pink to pinkish or brown in color. At this time, it is called lochia serosa. The vaginal discharge that normally occurs for 2 to 3 days after childbirth, lochia rubra, contains mostly blood and is dark red in color. A brown vaginal discharge is commonly associated with lochia serosa, the vaginal discharge from approximately day 4 through day 9.
A nurse is caring for a client who has returned to their room after a carotid endarterectomy. Which action should the nurse take first?
Ask the client if they have trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.
A nurse preparing to administer a scheduled dose of phenytoin intravenous (I.V.) push verifies that the client has a patent venous access site in the right hand with an infusion of dextrose solution at a rate of 50 mL/hour. In addition to following the rights of medication administration, which actions will the nurse take to give this drug safely? Select all that apply.
Calculate the I.V. rate., Initiate a new I.V. site in the forearm., Dilute the drug with sterile water. The rights of medication administration include giving the right drug and dosage to the right client at the right time through the right route. In addition, there are specific actions needed to safely administer certain medications. Phenytoin must be diluted in saline or sterile water because it will precipitate in dextrose solution. It will also cause hypotension and circulatory collapse if administered too quickly, thus a slow push rate is needed. Hand-vein access should be avoided to prevent discoloration.