Droplet precautions - ANS ✓The top edge of a surgical face mask should be
secured over the bridge of the nose just below the eyeglasses to provide a snugly-
fitting mask that prevents transmission of pathogens while the client is
transported outside the room. Transporting the client without protective
equipment endangers other persons who might come in contact with the client. A
fitted respirator-style mask is not necessary unless the clients placed on airborne
precautions for tuberculosis. Protective goggles are used by caregivers likely to
be in contact with potentially contaminated body fluids & do not need to be worn
by the client.
confused client- action - ANS ✓A confused client who is wandering is at risk for
injury. The nurse should orient the client to her surroundings, escort the client to
her room to promote sleep, & use a bed alarm to alert the nurse to further
wandering behavior.
Korotkoff sound-immediate - ANS ✓Kortkoff sounds describe blood pressure
from the first sound, which is a clear, rhythmic, tapping sound that corresponds
with systolic blood pressure, to the 5th sound which is a disappearance of all
sound & corresponds with diastolic blood pressure. If the 1st kortkoff sound is
heard immediately after releasing the valve, it means that the cuff was not
inflated high enough & all the air should be released & the cuff reflated to a
higher level.
Cyanosis- respiration rate - ANS ✓Cyanosis, a bluish discoloration, is an
indication of hypoxemia, so it is most important for the nurse to assess the
client's respiratory function first, followed by the remaining vital signs.
Oxygenation - ANS ✓Low O2 levels may cause confusion and combativeness, sot
he highest priority is assessment of peripheral O2 saturation, which evaluates
BSN 225
, 2
BSN
oxygenation to the brain as well as distal to the restraints. The anxiolytic may be
helpful, but can also mask symptoms, so this intervention may be necessary
when developing a plan of care. A sitter might be helpful, but assessment of O2
saturation guides further interventions.
Grimacing- assessment - ANS ✓Grimacing is a nonverbal sign of pain, so first
this sign should be clarified, The nurse should continue to monitor for nonverbal
signs of pain if the client continues to deny pain. The pain medication should be
reviewed to determine what is prescribed & then administer if the client admits
to pain or discomfort.
IM- mg/mL 0.4 mg : 1 ml= 0.4X=1 X=1/0.4 - ANS ✓=2.5 ml
Therapeautic communication - ANS ✓Reflecting how difficult the situation ust
befor the patient is an open-ended response the nurse should make that
encourages dialogue & addresses the parents feelings.
Pedal Pulse - ANS ✓Firm pressure may obliterate a weak pulse, sot he nurse
should 1st reduce the amount of pressure being applied at the site, If the pulse is
still not palpable, the nurse may use a doppler stethoscope.
Assess Feces - ANS ✓Multiple hard pallets may indicate problems with
constipation or inadequate fluid intake. A tarry appearance or read streaks may
indicate bleeding. Brown liquid may indicate diarrhea or decal impaction.
HIPAA- emancipated - ANS ✓The client has legally separated themselves from
their parents before they reach 18-years-old. Once emancipated, the law protects
them as an adult. Providing the client's parents with the results violateds HIPAA
requirements. According to HIPAA, no healthcare provider may share
information with another individual unless express consent has been given by
the client or assigned medical power of attorney has been established.
24 hour urine collection - ANS ✓The urine collected from the 1st specimen was
in the bladder before the 24 hour. Specimen collection was started, so it should
be discarded.
BSN 225
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