latest Assessment RN VATI Adult Medical Surgical
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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 irritation, increased swelling, and skin breakdown. Rem... ove 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 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. 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. [Show More]
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