Assessment RN VATI Adult Medical Surgical

Document Content and Description Below

Assessment RN VATI Adult Medical Surgical 2016 1. Inspect the client's skin underneath the boot every 12 hr. The nurse should inspect the client’s skin underneath the boot every 8 hr for irritatio... n, increased swelling, and skin breakdown. Remove the weights from the traction while repositioning the client in bed. MY ANSWER The nurse should not remove the weights from traction without a prescription from the provider. The purpose of the weight is to immobilize the hip prior to surgery and to decrease muscles spasms. Assess the client's circulation every 4 hr. The nurse should assess the client's circulation hourly for the first 24 hr to monitor for decreased perfusion and neurovascular changes. Request the client to perform dorsiflexion of the affected extremity every 1 hr. The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hr to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately. 2. Stop the blood transfusion immediately. A client who has type AB-positive blood is considered a universal recipient and can receive any ABO blood type. A client who has Rh-positive blood can receive a transfusion from a Rh-negative donor. Prepare to administer antipyretics. Febrile reactions are most often caused by leukocyte incompatibilities. Unless a client has a history of febrile reactions to prior transfusions or shows signs of chills or fever, there is no reason to administer antipyretics. Monitor the client for any adverse reactions. MY ANSWER Although a client is considered a universal recipient because he can receive any ABO blood type, the nurse should continue to monitor the client for any adverse reactions, which is standard procedure for any blood transfusion. Transfuse the blood over 6 hr. The nurse should transfuse the packed RBCs within 4 hr after removing it from refrigeration to reduce the risk of bacterial contamination of the blood. 3. Assess the client to determine the need for endotracheal suction every 4 hr. Evidence-based practice indicates the nurse should assess the client's need for endotracheal suction every 2 hr to ensure a clear airway. Check the ventilator settings every 12 hr. Evidence-based practice indicates the nurse should check the ventilator settings every 8 hr to make sure the settings are at the correct levels. Keep the head of the client's bed elevated 30°. MY ANSWER The nurse should keep the head of the client's bed elevated at least 30° to promote increased lung expansion and to help prevent ventilator-associated pneumonia. Perform oral hygiene with chlorhexidine every 3 hr. Evidence-based practice indicates the nurse should perform oral hygiene with chlorhexidine every 2 hr to help prevent ventilator-associated pneumonia from bacteria accumulating in the oral cavity and colonizing in the lower respiratory system. 4. High lipase A high lipase level is associated with pancreatic dysfunction or renal failure and is not an expected finding of hyponatremia or dehydration. Low urine specific gravity [Show More]

Last updated: 1 year ago

Preview 1 out of 37 pages