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• The normal therapeutic range for digoxin is 0.5 to 2.0 ng/ mL. A value of 1.0
is within therapeutic range, and the nurse would administer the next dose as
scheduled.
• Nurses need their own liability insurance for protection against malpractice
law suits. Nurses erroneously assume that they are protected by an agency’s
professional liability policies. Usually when a nurse is sued, the employer is
also sued for the nurse’s actions or inactions. Even though this is the norm,
nurses are encouraged to have their own malpractice insurance.
• In a fire emergency, the steps to follow use the acronym RACE. The
first step is to remove the victim. The other steps are: activate the
alarm, contain the fire, then evacuate as needed. This is a universal
standard that can be applied to any type of fire emergency. The
nurse first removes the victim from the area. Pulling the nearest fire
alarm would be the next step. The nurse next contains the fire and
then extinguishes the fire.
• Generally there are only two instances in which the informed consent of an
adult client is not needed. One instance is when an emergency is present and
delaying treatment for the purpose of obtaining informed consent would
result in injury or death to the client. The second instance is when the client
waives the right to give informed consent.
• The client with hyperphosphatemia should avoid foods that are naturally high
in phosphates. These include fish, eggs, milk products, vegetables, whole
grains, and carbonated beverages. Coffee, tea, and cocoa are not high in
phosphates.
• The nurse manager needs to attend to the client assignments first. Client
care is the priority. In addition, the nursing staff needs assignments so that
they can begin client assessments and begin delivering client care. The nurse
manager should next check the crash cart (which is normally done every
shift) to ensure that needed equipment is available in the event of an
emergency. The nurse manager could also delegate this task to another
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registered nurse while client assignments are being planned. The nurse
manager would next begin the problem-solving process related to finding a
charge nurse for the next shift. Since this activity directly affects client care,
this would be done before reading the stack of mail.
• The nurse needs to stay with the client and consult with the nurse manager
about the situation. It may be necessary for the nurse manager to contact the
supervisor to obtain an additional staff member to care for the client. Since
the client has a head injury, a major concern is the development of increased
intracranial pressure (ICP). The application of restraints may agitate the
client, causing further restlessness and thus increasing ICP. A nursing
assistant is not trained to monitor for increased ICP. It is inappropriate to ask
a family member to sit with the client.
• External disasters occur in the community, and many victims may be brought
to the emergency room for care. In this situation, the nurse manager would
initially contact the nursing supervisor about the need for additional staffing
and to discuss activation of the disaster plan. The nurse manager should ask,
not demand that nurses from the night shift stay until all of the victims are
treated. The nurse manager would not ask emergency medical services to
take the victims to another hospital or close the emergency room temporarily
to incoming clients. These decisions are made by administration.
• Most minor burns can be handled at home by the parents. For minor burns,
exposure to cool running water is the best treatment. This stops the burning
process and helps to alleviate pain. Ice is contraindicated, because it may
add more damage to already injured skin.
• When a bee sting occurs and is painful, it is best to treat the site locally
rather than systemically. Pain can be alleviated by applying an ice pack and
elevating the site.
• When a Salem sump tube is connected to suction, the air vent permits a free,
continuous flow of secretions. The air vent should never be clamped or tied
off, connected to suction, or used for irrigation. The nurse manager should
handle this problem directly with the nurse who is performing this action and
should initially review the skills checklist of the nurse who is tying the knots
to assess if this skill has ever been performed and validated.
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infusion rate of the nonadditive IV solution is increased. The client is
positioned in a side-lying position, and oxygen via a snug facemask is
administered at 8 to 10 liters per minute. The physician is notified of the
adverse reactions, the nursing interventions that have been implemented,
and the client’s response to the interventions. The maternal blood pressure is
monitored closely.
• Severe leg pain, once traction has been established, indicates a problem. A
client who complains of severe pain may need realignment or may have
traction weights ordered that are too heavy. The nurse realigns the client,
and if that is ineffective, then calls the physician. The nurse never removes
traction weights unless specifically prescribed by the physician. The client
should be medicated only after an attempt has been made to determine and
treat the cause.
• The nurse should monitor the client’s heart rate and pulse oximetry during
suctioning to assess the client’s tolerance of the procedure. Oxygen
desaturation below 90% indicates hypoxemia. If hypoxia occurs during
suctioning, the nurse terminates the suctioning procedure. Using the 100%
oxygen delivery system, the client is reoxygenated until baseline parameters
are achieved. The size of the catheter should not exceed half the size of the
tracheal lumen. In adults, the standard catheter size is 12 to 14 French.
Adequate catheter size facilitates efficient removal of secretions without
causing hypoxemia.
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• In most situations, clamping of chest tubes is contraindicated, and
agency policy and procedure must be followed with regard to
clamping a chest tube. When the client has a residual air leak or
pneumothorax, clamping the chest tube may precipitate a tension
pneumothorax because the air has no escape route. If the tube
becomes disconnected, it is best to immediately reattach it to the
drainage system or to submerge the end in a bottle of sterile water
or saline to reestablish a water seal. If sterile water or saline is not
readily available, it is preferable to leave the tube open because the
risk of tension pneumothorax outweighs the consequences of an
open tube. The physician may need to be notified, but this is not the
immediate action. The client would not be instructed to inhale.
• Surface foreign bodies are often removed simply by irrigating the eye with
sterile normal saline. The nurse would not use clamps because this action will
risk causing further injury to the eye. Applying an eye patch would not
provide relief for the problem. Visual acuity tests are not the priority at this
time, and might not be feasible because the client most likely has excessive
blinking and tearing as well at this time.
• Ritonavir (Norvir) oral solution is prescribed to a client with HIV virus. The
drug is preferably administered with food. It may be mixed with chocolate
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milk or a dietary supplement to improve the taste. The client is also
instructed to consume the dose within 1 hour of mixing.
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the client should consume a light meal, such as dry toast, juice, or a
bowl of cereal with milk. Unexplained weight loss needs to be
reported to the physician.
• The ultimate responsibility for a task lies with the person who delegated it.
Therefore, it is the nurse’s primary responsibility to follow up with each staff
member regarding the performance of the task and the outcomes related to
implementing the task. Not all staff members have the education, knowledge,
and ability to make judgments about tasks being performed. The nurse would
document that the task was completed but this would not be done until
follow-up was implemented and outcomes were identified. It is not
appropriate to assign the tasks that were not completed to the next nursing
shift.
• The client with a thoracic burn and smoke inhalation requires aggressive
pulmonary measures to prevent atelectasis and pneumonia. These include
turning and repositioning, using humidified oxygen, providing incentive
spirometry, and suctioning on an as-needed basis. The client should not be
left lying in a single position and should not have the head of bed flat. These
could promote the development of complications by limiting chest expansion.
• The client with diabetic neuropathy of the lower extremities has diminished
ability to feel sensations in the legs and feet. This client is at risk for tissue
injury and for falls as a result of this nervous system impairment.
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weight gain. The diet should be low in calories overall and yet be
representative of all food groups.
• Constant bubbling in the water seal chamber of a closed chest tube drainage
system may indicate the presence of an air leak. The nurse would assess the
chest tube system for the presence of an external air leak if constant
bubbling were noted in this chamber. If no external air leak is present, the
physician is notified immediately because an air leak may be present in the
pleural space. Leaking and trapping of air in the pleural space can result in a
tension pneumothorax.
• The client taking NPH insulin obtains peak medication effects 6 to 12 hours
after administration. At the time that the medication peaks, the client is at
risk of hypoglycemia if food intake is insufficient. The nurse would teach the
client to watch for signs and symptoms of hypoglycemia, including anxiety,
confusion, difficulty concentrating, blurred vision, cold sweating, headache,
increased pulse, shakiness, and hunger.
• Before doing a fingerstick for blood glucose measurement, the client should
first wash the hands. Warm water should be used to stimulate the circulation
to the area. The finger is punctured near the side, not the center, since there
are fewer nerve endings along the side of the finger. The puncture is only
deep enough to obtain an adequately sized drop of blood; excessively deep
punctures can lead to pain and bruising. The arm should be allowed to hang
dependently, and the finger can be milked to promote obtaining a good size
blood drop.
• The client with DKA initially becomes hyperkalemic as potassium leaves the
cells in response to a lowered pH. Once fluid replacement and insulin therapy
are started, the potassium level drops quickly. This occurs because
potassium is carried into the cells along with glucose and insulin, and also
because potassium is excreted in the urine once rehydration has occurred.
Thus, the nurse must plan to monitor the results of serum potassium levels
carefully, and report hypokalemia.
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