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Seizure precautions
- ✔ Ensure client has IV access for seizure medication administration.
Postoperative lab values
- ✔ Report Hgb level of 8 g/dL to provider as an indicator of postoperative
hemorrhage or anemia.
ESWL procedure
- ✔ Expect stone fragments in the urine after extracorporeal shock wave
lithotripsy.
Airborne precautions
- ✔ Initiate airborne precautions for a client with anorexia, low-grade fever, night
sweats, and productive cough, as these are manifestations of tuberculosis.
TPN administration
- ✔ Administer dextrose 10% in water until new TPN bag arrives to avoid drop in
blood glucose level.
Levothyroxine interaction
- ✔ Instruct client to avoid taking calcium within 4 hr of levothyroxine
administration, as calcium can interfere with the effectiveness of the medication.
Mechanical ventilation anxiety
- ✔ Instruct client to allow the machine to breathe for them to reduce anxiety
and restlessness associated with fighting the ventilator.
Adverse effect of enalapril
✔ Identify orthostatic hypotension as an adverse effect of enalapril.
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Delayed wound healing
- ✔ Identify urine output of 25 mL/hr as a finding that contributes to delayed
wound healing.
Hypothyroidism and opioid analgesic
- ✔ Instruct client to void every 4 hours to decrease the risk of urinary retention,
which is an adverse effect of opioid analgesics.
Portal hypertension
- ✔ Obtain vital signs first when caring for a client who is vomiting blood mixed
with food after a meal, as this indicates a potential rupture of esophageal varices.
Gastrectomy postoperative instructions
✔ Instruct client to avoid drinking fluids with meals, eat several small meals per
day, consume high-protein snacks, and avoid highly seasoned foods.
Cushing's triad
- ✔ Identify bradycardia as a component of Cushing's triad in a client with
increased intracranial pressure from a traumatic brain injury.
Client coping with diabetes diagnosis
- ✔ Recognize the client's change in behavior of inspecting feet daily as an
indication of successful coping with the diagnosis.
Inguinal hernia assessment
- ✔ Palpate location C to verify the presence of an inguinal hernia.
Rattlesnake bite treatment
- ✔ Expect a prescription for an opioid analgesic to promote comfort following a
rattlesnake bite.