Priority Nursing Actions

Patient with burn injuries

1. Assess for airway patency 2. Administer oxygen as prescribed 3. Obtain vital signs 4. Assist to initiate an IV line and begin fluid replacement as prescribed 5. Elevate the extremities if not fractures are obvious 6. Keep the client warm and place the client on NPO status

Client experiencing a hypoglycemic reaction

1. Check the client's blood glucose level 2. Give the client a 10 to 15 gm carbohydrate item, such as 1/2 cup of fruit juice, to drink (if client is not responsive or is unable to swallow, assist the RN in preparation of an IV injection of 25 to 50 mL of 50% dextrose in water 3. Take the client's vital signs 4. Retest the blood glucose level in 15 min 5. Give the client a small snack of carbohydrate and protein 6. Document the clients complaints, action taken and outcome

Sealed Radiation Implant becomes dislodge

1. Encourage the client to lie still 2. Use a long-handled forceps to retrieve the radioactive source 3. Deposit the radioactive source in a lead container 4. Contact the RN and radiation oncologist 5. Document the occurrence and the actions taken

Client with a Paracentesis

1. Ensure that the client understands the procedure and that informed consent has been obtained 2. Obtain vital signs, including weight 3. Have the client void 4. Position the client upright 5. Assist the HCP. Monitor the v/s and provide comfort and support during the procedure 6. Apply a dressing to the site of puncture (monitor for leakage or bleeding) 7. Weight the client, and maintain the client on bed rest 8. Measure the amount of fluid removed 9. Label and send the fluid for laboratory analysis 10. Document the event, client's response, and appearance and amount of fluid removed 11. Nurse should also monitor for hypovolemia, electrolyte loss, mental status changes, or encephalopathy)

Performing Respiratory Suctioning

1. Explain the procedure to the client 2. Assist the client to an upright position (semi-fowlers) 3. Perform hand hygiene and don protective garb 4. Prepare suctioning equipment and turn on the suction 5. Hyperoxygenate the client 6. Insert the catheter without suction applied 7. Once inserted, apply suction intermittently (up to 10sec) while rotating and withdrawing the catheter 8. Hyperoxygenate the client 9. Listen to breath sounds 10. Document the procedure, client response, and effectiveness

Pulmonary Embolism is Suspected

1. Notify the Rapid Response Team 2. Reassure the client and elevate the head of the bed 3. Prepare to administer oxygen 4. Obtain v/s and check lung sounds 5. Prepare to obtain an arterial blood gas 6. Prepare for the administration of heparin therapy or other therapies 7. Document the event, interventions taken, and the client's response to treatment

Actions taken when Allen's Test is Performed before Radial Artery Puncture

1. The procedure is explained to the client 2. Pressure is applied over the ulnar and radial arteries simultaneously. 3. The client is asked to open and close the hand repeatedly 4. Pressure is released from the ulnar artery while compressing the radial artery 5. The color of the extremity distal to the pressure point is checked (Should return in 6 to 7 sec) 6. The findings are documented.

Anaphylactic Reaction Occurs from Medication

1.Respiratory status is assessed 2. The medication is stopped 3. The HCP is contacted by the RN; the Rapid Response Team is also contacted if necessary 4. Oxygen is administered 5. The client's feet and legs are raised, if not contraindicated; head of the bed is elevated 10* if hypotension is present, 45* or higher if BP is normal. 7. Prescribed emergency medications are administered (diphenhydramine, Benadryl or epinephrine) 8. Vital signs are monitored 9. The event actions taken, and the client's response are documented.