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Clinical Midterm NUR256 SP21
Terms in this set (46)
What is the first task a nurse should do after getting a post-op client?
Auscultate breath sounds to observe for the development of atelectasis.
What would a nurse do after auscultating a post op patient?
Monitor vital signs (including temperature, pulse, blood pressure, oxygen saturation, pain level).
What should the nurse do after monitoring vital signs when taking care of a post op client?
Assists/instructs in coughing and deep breathing exercises with splinting techniques.
With a post op patient, what should the nurse do after assisting patient to cough and deep breath?
Observe for the development of fluid volume imbalance.
With a post op patient, what should the nurse do after observing for fluid volume imbalance?
Assists/instructs in ankle circles and calf pumps.
With a post op patient, what would the nurse do after assisting/instructing in ankle circles and calf pumps?
Assists with early ambulation. Assists client in getting out of bed (OOB), protecting incision and IV site.
With a post op patient, what would the nurse do after assisting client with early ambulation?
Reinforces surgical dressing. Changes dressing using sterile technique as ordered.
With a post op patient, what would the nurse do after reinforcing surgical dressing?
Observes for incisional line complications (e.g. dehiscence, evisceration)
With a post op patient, what would the nurse do after observing incisional line?
Secures tubing/drains to client's gown to prevent dislodgement.
With a post op patient, what would the nurse do after securing the tubing to the patient?
Auscultate for the return of bowel sounds. Progresses diet from clear liquids when bowel sounds return and within physician orders.
With a post op patient, what would the nurse do after auscultating for the return of bowel sounds?
Maintains patency of urinary catheter; once discontinued, observes for development of urinary retention and urinary tract infection.
With a post op patient, what would the nurse do after maintaining patency of urinary catheter?
Assure client comfort at all times and proper positioning/alignment.
With a post op patient, what would the nurse do after assuring client comfort?
Listens to feelings and concerns.
With a post op patient, what would the nurse do after listening to the feelings and concerns?
Provides discharge instruction on activity restrictions, diet, incisional care, and signs and symptoms of infection.
What should a nurse do first if they are caring for a TPN patient?
Verify TPN components with current physician orders (new orders required daily)and medical administration record (MAR)
After verifying the TPN, what should you do next?
Correlate dosage change with serum lab values and client assessment.
With a TPN patient, what should you do after correlating the dosage?
Inspect TPN/Lipid solution. If TPN/Lipid solution is unavailable, Hang D10 and notify pharmacy (hypoglycemia may result from abruptly stopping TPN).
With a TPN patient, what should you do after inspecting TPN/lipid solution?
Warm solution to room temperature prior to hanging
With a TPN patient, what should you do after warming solution?
Provide client instruction on purpose of TPN
With a TPN patient, what should you do after giving client instruciton?
Assess central line insertion site; only solutions containing <10% dextrose may be administered peripherally.
You hang solution according to hospital policy. What are the following possibilities?
Usually between hours of 1800-2100, with new tubing and micron filter every 24 hours, via pump and separate from other solutions. No medications to be administered via the TPN line, accu-checks regularly to assess for hyper/hypoglycemia.
How would you maintained the ordered flow rate?
Initial infusion rate is slow (50 mL/hr) as ordered, increase rate by 25 mL/hr until desired rate achieved, monitor accuracy of volume delivered at least every 4 hours, decrease rate in increments to wean if discontinuing.
With a TPN patient how will you monitor the client's ?
Weigh as ordered, maintain accurate intake and output, blood sugar every 6 hours is nothing per os (NPO) or before meals and bedtime if taking oral foods, monitor laboratory values and communicate with MD/pharmacist, vital signs every four hours and prn
How do you assess for TPN complications?
Infection, hypo/hyperglycemia, fluid volume excess/deficit, electrolyte imbalance, allergic reaction. Pneumothorax, bleeding from insertion site, air embolism, infiltration, phlebitis
What should the first nursing task be when it comes to the patient with diabetes?
Make sure the student nurse is familiar with the diabetic medications the client is taking and can state the onset, peak and duration of the medications.
With a diabetic client, what should a nurse do after they are familiar with their diabetic medication?
An assessment would be done immediately upon assuming care for the client.
With a diabetic client, what should a nurse do after the assessment?
Vital signs, blood sugar level, and LOC are priority assessments performed.
With a diabetic client, what should a nurse monitor for during the shift?
hypo and hyperglycemia and micro- and macro- diabetic complications
With a diabetic client, what should a nurse do with the medications?
Administer them timely and accurately.
With a diabetic client, what should a nurse do when it comes to the patient's diet?
Diet is to be administered timely; intake and output assessed.
How should a nurse monitored a diabetic diet who is NPO?
The student assess for caloric intake necessary o counterbalance medication given.
What should a nurse do if an imbalance exists?
Tack actions to remedy the situation.
Clinical manifestations of hypokalemia?
Fatigue, dysrhythmias, muscle weakness (leg cramps/paresthesia, glucose intolerance, decreased muscle strength, cardiac output, polyuria/altered renal function.
Clinical manifestations of hyperkalemia?
Cardiac changes, dysrhythmias, possible cardiac arrest, potential respiratory impairment, muscle weakness, paresthesia, tremors, twitching, anxiety, GI manifestations
Clinical manifestation of hyponatremia?
Poor skin turgor, dry mucosa, headache, decreased salivation and BP, nausea, abdominal cramping, neuro changes, muscle weakness.
Clinical manifestation of hypernatremia?
Thirst, elevated temperature, dry and swollen tongue, sticky mucosa, neuro symptoms, restlessness, weakness, seizures or coma.
Clinical manifestation of hypocalcemia?
Tetany (spasms), circumoral numbness, paresthesia, hyperactive DTR's, Troussau's sign, Chvostek's sign, seizures, respiratory symptoms, dyspnea
What are the clinical manifestations of hypermagnesemia?
Flushing, decrease BP, diminished DTRs, Drowsiness, muscle weakness, depressed respirations, EKG changes, dysrhythmias, coma/cardiac arrest
What is the generic name for Aldactone?
What are the classifications for Aldactone?
Diuretics, Potassium-sparing Diuretics.
What is the therapeutic effect of Aldactone?
Increased survival in patients with severe heart failure (New York Heart Association class II-IV). Weak diuretic and antihypertensive response when compared with other diuretics. Conservation of potassium.
What is the action of drug Aldactone?
Causes loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions by antagonizing aldosterone.
What are the contraindications in Aldactone?
Hypersensitivity, anuria, acute renal insufficiency, significant renal impairment, hyperkalemia, addison's disease, concurrent use of eplerenone.
What are toxic side effects of Aldactone?
DRUG RASH WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS,
What are the nursing interventions for Aldactone?
Monitor intake and output ratios and daily weight during therapy. If medication is given as an adjunct to antihypertensive therapy, BP should be evaluated before administering. Assess patient frequently for development of hyperkalemia (fatigue, muscle weakness, paresthesia, confusion, dyspnea, cardiac arrhythmias).
What are the safe dosage for Aldactone?
Safe Dosage: 25-400 mg/day as a single dose or 2 divided doses. HF- 25-50 mg/day.
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