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A nurse is administering packed red blood cells to a client. What should the nurse do if a transfusion reaction is suspected? Stop the infusion. A nurse is caring for a client with skeletal traction following a fracture. How and when should skeletal pin care be provided? One cotton swab with chlorhexidine is designated for each pin for pin care to be done once a shift. A nurse is providing dietary teaching to a client newly diagnosed with constipation-predominant irritable bowel syndrome. List two (2) teaching points the should share with the client about dietary practices. Eat foods high in fiber Increase fluids Late Cushing's Triad manifestation Severe hypertension with widening of pulse pressure and bradycardia Identifying Basal cell cancer small, waxy nodule with superficial blood vessels, well-defined borders Teaching post Bronchoscopy assess LOC, cough and gag reflex, and ability to swallow before consuming oral intake Teaching how to prevent transmission of HIV take antiretroviral medications to inhibit DNA synthesis and Viral replication ABGs Determine imbalance ... Blood compatibility: Nursing Actions for Hemolytic transfusion reaction Remove the blood tubing from the IV access site. Initiate an infusion of 0.9% of sodium chloride using new tubing. Monitor VS and fluid status. Send the blood bag and administrating set to the lab for testing. Priority intervention for Complication of Central Venous Catheter 1) look for safety risk; what is the risk for patient and how significant is the risk? 2) Teaching about levothyroxine (overdose manifestations) overmedication can result thyrotoxicosis (anxiety, tachycardia, heat intolerance, fever, diaphoresis, weight loss, palpatations, chest pain, abd pain, nervousness, tremors Care of a perpherially inserted central catheter infusion system access site for redness, swelling, drainage, tenderness, and condition of the dressing. Evaluating effectiveness of fluid replacement hematocrit, increase hypovolemia Caring for pt with peritoneal dialysis: monitor for signs of infection (bloody, cloudy or frothy dialysate return, monitor for complications: respiratory distress, abd pain, insufficient flow, and discolored outflow Identifying reaction to radiation therapy skin blanching, erthyma, sloughing, desquamous, hemorrhage Priority action following surgical repair of abdominal aortic aneurysm Look for risk, monitor incision site, report infection Manifestations of diverticular Disease acute onset of abdominal pain often in left lower quadrant Right sided Heart Failure findings jugular vein distension, edema in legs, ankle and sacrum, abd distension, ascites, fatigue, weakness, nausea, anorexia, nocturnal polyuria, heptomegaly and tenderness, weight gain Cushing's Disease findings (too much cortisol hormone) fx or osteoporoesis, mnemonic: STRESSED S=skin fragile T=truncal obesity with small arms R=rounded face (moon shaped-like); Reproductive issues: ammenorrhea in women, erectile dysfx in males E=ecchymosis, Elevated BP S=striae on the extremities and abd S=sugar extremely high (hyperglycemia) E=excessive body hair...Hirsutism (women starting to have male chara), and Electrolyte imbal: hypokalemia D=Dorsocervical fat pad (buffalo hump), Depression Labs normal ranges Mg 1.3-2.1 mEq/L , high levels lead to dysrhythmias and cardiac arrest Ca 9.0 to 10.5 mg/dL Na 136 to 145 mEq/L WBC 5,000 to 10,000/mm3 urine specific gravity 1.005-1.030 hematocrit m 40-54%, f 39-47%, child 32-44%, NB 49-54% BUN 5-18mg/dL creatine m 0.7-1.3mg/dL, f 0.5-1.1mg/dL triglycerides m 40-160 mg/dL, f 35-135mg/dL Albumin 3.5-5g/dL, greater than 5.5 is malnutrition aPTT 60-80 seconds, INR 2.5-3.5 alkaline phosphorous 30-120U/L, less than 30=malnutrition, greater 120=bone/liver disorders Raynaud's syndrome-prescription for nifedipine (Procardia, Adalat.) relaxes smooth muscle & improves circulation -reducing finger membranes Acute appendicitis findings fever, tachycardia, diffuse abd pain, complications: peritonitis Large intestine dx test flexible sigmoidoscopy Antidiarrheal drugs camphorated tincture of opium diphenoxin diphenoxylate laudanum loperamide hydrochloride Intervention for moderate stages of Alzheimer's disease provide protective undergarments Pressure Sore Risk factors part of the Braden Scale Friction and Shear/ Nutrition Oral contraceptive teaching take med immediately if client forgot this morning Findings for deep partial thickness burn 40% of his body dyspnea, hyperkalemia, hyponatremia Prednisone knowledge induces body to stop producing natural steroids and pt might have a crisis Rheumatoid arthritis manifestations swelling of bilateral joints, ulner deviation, morning joint stiffness