Assessment RN VATI Adult Medical Surgical 2016

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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 irritat... ion, increased swelling, and skin breakdown. Remove the weights from the traction while repositioning the client in bed. 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. 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°. 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 5. "I will adjust the rate of infusion based on my urinary output." The nurse should teach the client to monitor urinary output. However, the client should administer PN at a consistent rate prescribed by the provider. An infusion rate that is too rapid can cause hyperosmolar diuresis and hyperglycemia. A rate that is too slow can result in inadequate caloric and nutritional intake. "I will need to have a 60-milliliter syringe to administer my PN." The nurse should teach the client to use an electronic infusion device to prevent the accidental overload of the intravenous PN solution. A 60-mL syringe is used for intermittent bolus enteral tube feedings. "I will keep additional solution bags at room temperature." The nurse should teach the client to refrigerate any PN solution that is not infusing to decrease the risk of bacterial growth. PN solution is an ideal environment for bacterial growth because of the high dextrose and fat content. 6. The stool will have a pasty texture. 7. Sudden, severe onset of hypertension Sudden, severe onset of hypertension is a late manifestation of increased intracranial pressure, which is a component of Cushing's triad. Therefore, there is another finding that is the first manifestation of a change in neurological status. Bradycardia Bradycardia is a late manifestation of increased intracranial pressure, which is a component of Cushing's triad. Therefore, there is another finding that is the first manifestation of the change in neurological status. Widened pulse pressure Widened pulse pressure is a late manifestation of increased intracranial pressure, which is a component of Cushing’s triad. Therefore, there is another finding that is the first manifestation of a change in neurological status. Change in level of consciousness 9. Auscultate the client's abdomen for a bruit. The nurse should auscultate the client's abdomen for a bruit to assess for a renal artery injury or an abdominal aortic aneurysm. Check the client for fecal impaction. The nurse should monitor bowel movements and check the client for fecal impaction that can cause an increase in intra-abdominal pressure. Place the client in a supine position. 10. "I will eat a light breakfast the morning of the test." An OGTT is a fasting test, and the client should remain NPO for 12 hr prior to the test. "I should expect to drink a beverage containing glucose before the first blood draw." 12. Oral temperature of 37.2° C (99° F) The nurse should expect a slight elevation of the client's temperature postoperatively. However, an increased temperature elevation or a spike can indicate an infection. Clear drainage on the dressings Each nurse's badge measures the amount of exposure to the radiation. ………………………………………………CONTINUED………………………………………….. [Show More]

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