Questions and Answers
Enalapril4Vmaleate4Vis4Vprescribed4Vfor4Va4Vhospitalized4Vclient.4VWhich4Vassessme
nt4Vdoes4Vthe4Vnurse4Vperform4Vas4Va4Vpriority4Vbefore4Vadministering4Vthe4Vmedicat
ion?
Checking4Vthe4Vclient's4Vblood4Vpressure4V
Checking4Vthe4Vclient's4Vperipheral4Vpulses
Checking4Vthe4Vmost4Vrecent4Vpotassium4Vlevel
Checking4Vthe4Vclient's4Vintake-and-output4Vrecord4Vfor4Vthe4Vlast4V244Vhours4V-
4VANSWERSChecking4Vthe4Vclient's4Vblood4Vpressure4V
Rationale:4VEnalapril4Vmaleate4Vis4Van4Vangiotensin-
converting4Venzyme4V(ACE)4Vinhibitor4Vused4Vto4Vtreat4Vhypertension.4VOne4Vcomm
on4Vside4Veffect4Vis4Vpostural4Vhypotension.4VTherefore4Vthe4Vnurse4Vwould4Vcheck4
Vthe4Vclient's4Vblood4Vpressure4Vimmediately4Vbefore4Vadministering4Veach4Vdose.4V
Checking4Vthe4Vclient's4Vperipheral4Vpulses,4Vthe4Vresults4Vof4Vthe4Vmost4Vrecent4Vp
otassium4Vlevel,4Vand4Vthe4Vintake4Vand4Voutput4Vfor4Vthe4Vprevious4V244Vhours4Var
e4Vnot4Vspecifically4Vassociated4Vwith4Vthis4Vmediation.
A4Vclient4Vis4Vscheduled4Vto4Vundergo4Van4Vupper4Vgastrointestinal4V(GI)4Vseries,4Va
nd4Vthe4Vnurse4Vprovides4Vinstructions4Vto4Vthe4Vclient4Vabout4Vthe4Vtest.4VWhich4Vst
atement4Vby4Vthe4Vclient4Vindicates4Va4Vneed4Vfor4Vfurther4Vinstruction?
"The4Vtest4Vwill4Vtake4Vabout4V304Vminutes."
"I4Vneed4Vto4Vfast4Vfor4V84Vhours4Vbefore4Vthe4Vtest."
"I4Vneed4Vto4Vdrink4Vcitrate4Vof4Vmagnesia4Vthe4Vnight4Vbefore4Vthe4Vtest4Vand4Vgive
4Vmyself4Va4VFleet4Venema4Von4Vthe4Vmorning4Vof4Vthe4Vtest."4V
"I4Vneed4Vto4Vtake4Va4Vlaxative4Vafter4Vthe4Vtest4Vis4Vcompleted,4Vbecause4Vthe4Vliqu
id4Vthat4VI'll4Vhave4Vto4Vdrink4Vfor4Vthe4Vtest4Vcan4Vbe4Vconstipating."4V-
4VANSWERS"I4Vneed4Vto4Vdrink4Vcitrate4Vof4Vmagnesia4Vthe4Vnight4Vbefore4Vthe4Vte
st4Vand4Vgive4Vmyself4Va4VFleet4Venema4Von4Vthe4Vmorning4Vof4Vthe4Vtest."4V
Rationale:4VNo4Vspecial4Vpreparation4Vis4Vnecessary4Vbefore4Va4VGI4Vseries,4Vexcep
t4Vthat4VNPO4V(nothing4Vby4Vmouth)4Vstatus4Vmust4Vbe4Vmaintained4Vfor4V84Vhours4V
before4Vthe4Vtest.4VAn4Vupper4VGI4Vseries4Vinvolves4Vvisualization4Vof4Vthe4Vesopha
gus,4Vduodenum,4Vand4Vupper4Vjejunum4Vby4Vmeans4Vof4Vthe4Vuse4Vof4Va4Vcontrast
4Vmedium.4VIt4Vinvolves4Vswallowing4Va4Vcontrast4Vmedium4V(usually4Vbarium),4Vwhi
ch4Vis4Vadministered4Vin4Va4Vflavored4Vmilkshake.4VFilms4Vare4Vtaken4Vat4Vintervals4
Vduring4Vthe4Vtest,4Vwhich4Vtakes4Vabout4V304Vminutes.4VAfter4Van4Vupper4VGI4Vseri
es,4Vthe4Vclient4Vis4Vprescribed4Va4Vlaxative4Vto4Vhasten4Velimination4Vof4Vthe4Vbariu
m.4VBarium4Vthat4Vremains4Vin4Vthe4Vcolon4Vmay4Vbecome4Vhard4Vand4Vdifficult4Vto4
Vexpel,4Vleading4Vto4Vfecal4Vimpaction.
A4Vnurse4Von4Vthe4Vevening4Vshift4Vchecks4Va4Vprimary4Vhealth4Vcare4Vprovider's4Vp
rescriptions4Vand4Vnotes4Vthat4Vthe4Vdose4Vof4Va4Vprescribed4Vmedication4Vis4Vhighe
,r4Vthan4Vthe4Vnormal4Vdose.4VThe4Vnurse4Vcalls4Vthe4Vprimary4Vhealth4Vcare4Vprovid
er's4Vanswering4Vservice4Vand4Vis4Vtold4Vthat4Vthe4Vprimary4Vhealth4Vcare4Vprovider4
Vis4Voff4Vfor4Vthe4Vnight4Vand4Vwill4Vbe4Vavailable4Vin4Vthe4Vmorning.4VWhat4Vshould4
Vthe4Vnurse4Vdo4Vnext?
Call4Vthe4Vnursing4Vsupervisor
Ask4Vthe4Vanswering4Vservice4Vto4Vcontact4Vthe4Von-
call4Vprimary4Vhealth4Vcare4Vprovider4V
Withhold4Vthe4Vmedication4Vuntil4Vthe4Vprimary4Vhealth4Vcare4Vprovider4Vcan4Vbe4Vre
ached4Vin4Vthe4Vmorning
Administer4Vthe4Vmedication4Vbut4Vconsult4Vthe4Vprimary4Vhealth4Vcare4Vprovider4Vw
hen4Vhe4Vbecomes4Vavailable4V-
4VANSWERSAsk4Vthe4Vanswering4Vservice4Vto4Vcontact4Vthe4Von-
call4Vprimary4Vhealth4Vcare4Vprovider4V
Rationale:4VThe4Vnurse4Vhas4Va4Vduty4Vto4Vprotect4Vthe4Vclient4Vfrom4Vharm.4VA4Vnu
rse4Vwho4Vbelieves4Vthat4Va4Vprimary4Vhealth4Vcare4Vprovider's4Vprescription4Vmay4V
be4Vin4Verror4Vis4Vresponsible4Vfor4Vclarifying4Vthe4Vprescription4Vbefore4Vcarrying4Vit
4Vout.4VTherefore4Vthe4Vnurse4Vwould4Vnot4Vadminister4Vthe4Vmedication;4Vinstead,4V
the4Vnurse4Vwould4Vwithhold4Vthe4Vmedication4Vuntil4Vthe4Vdose4Vcan4Vbe4Vclarified.4
VThe4Vnurse4Vwould4Vnot4Vwait4Vuntil4Vthe4Vnext4Vmorning4Vto4Vobtain4Vclarification.4
VIt4Vis4Vpremature4Vto4Vcall4Vthe4Vnursing4Vsupervisor.
An4Vemergency4Vdepartment4V(ED)4Vnurse4Vis4Vmonitoring4Va4Vclient4Vwith4Vsuspect
ed4Vacute4Vmyocardial4Vinfarction4V(MI)4Vwho4Vis4Vawaiting4Vtransfer4Vto4Vthe4Vcoron
ary4Vintensive4Vcare4Vunit.4VThe4Vnurse4Vnotes4Vthe4Vsudden4Vonset4Vof4Vpremature
4Vventricular4Vcontractions4V(PVCs)4Von4Vthe4Vmonitor,4Vchecks4Vthe4Vclient's4Vcaroti
d4Vpulse,4Vand4Vdetermines4Vthat4Vthe4VPVCs4Vare4Vnot4Vperfusing.4VWhat4Vis4Vthe4
Vnurse's4Vmost4Vappropriate4Vaction?
Document4Vthe4Vfindings
Ask4Vthe4VED4Vprimary4Vhealth4Vcare4Vprovider4Vto4Vcheck4Vthe4Vclient4V
Continue4Vto4Vmonitor4Vthe4Vclient's4Vcardiac4Vstatus
Inform4Vthe4Vclient4Vthat4VPVCs4Vare4Vexpected4Vafter4Van4VMI4V-
4VANSWERSAsk4Vthe4VED4Vprimary4Vhealth4Vcare4Vprovider4Vto4Vcheck4Vthe4Vclient
4V
Rationale:4VThe4Vmost4Vappropriate4Vaction4Vby4Vthe4Vnurse4Vwould4Vbe4Vto4Vask4Vt
he4VED4Vhealth4Vcare4Vprovider4Vto4Vcheck4Vthe4Vclient.4VPVCs4Vare4Va4Vresult4Vof4V
increased4Virritability4Vof4Vventricular4Vcells.4VPeripheral4Vpulses4Vmay4Vbe4Vabsent4
Vor4Vdiminished4Vwith4Vthe4VPVCs4Vthemselves4Vbecause4Vthe4Vdecreased4Vstroke4
Vvolume4Vof4Vthe4Vpremature4Vbeats4Vmay4Vin4Vturn4Vdecrease4Vperipheral4Vperfusio
n.4VBecause4Vother4Vrhythms4Valso4Vcause4Vwidened4VQRS4Vcomplexes,4Vit4Vis4Ves
sential4Vthat4Vthe4Vnurse4Vdetermine4Vwhether4Vthe4Vpremature4Vbeats4Vare4Vresulti
ng4Vin4Vperfusion4Vof4Vthe4Vextremities.4VThis4Vis4Vdone4Vby4Vpalpating4Vthe4Vcarotid
,4Vbrachial,4Vor4Vfemoral4Vartery4Vwhile4Vobserving4Vthe4Vmonitor4Vfor4Vwidened4Vco
mplexes4Vor4Vby4Vauscultating4Vfor4Vapical4Vheart4Vsounds.4VIn4Vthe4Vsituation4Vof4V
acute4VMI,4VPVCs4Vmay4Vbe4Vconsidered4Vwarning4Vdysrhythmias,4Vpossibly4Vheral
ding4Vthe4Vonset4Vof4Vventricular4Vtachycardia4Vor4Vventricular4Vfibrillation.4VTherefor
e,4Vthe4Vnurse4Vwould4Vnot4Vtell4Vthe4Vclient4Vthat4Vthe4VPVCs4Vare4Vexpected.4VAlth
,ough4Vthe4Vnurse4Vwill4Vcontinue4Vto4Vmonitor4Vthe4Vclient4Vand4Vdocument4Vthe4Vfin
dings,4Vthese4Vare4Vnot4Vthe4Vmost4Vappropriate4Vactions4Vof4Vthose4Vprovided.
NPO4Vstatus4Vis4Vimposed4V84Vhours4Vbefore4Vthe4Vprocedure4Von4Va4Vclient4Vsched
uled4Vto4Vundergo4Velectroconvulsive4Vtherapy4V(ECT)4Vat4V14Vp.m.4VOn4Vthe4Vmorni
ng4Vof4Vthe4Vprocedure,4Vthe4Vnurse4Vchecks4Vthe4Vclient's4Vrecord4Vand4Vnotes4Vth
at4Vthe4Vclient4Vroutinely4Vtakes4Van4Voral4Vantihypertensive4Vmedication4Veach4Vmo
rning.4VWhat4Vaction4Vshould4Vthe4Vnurse4Vtake?
Administer4Vthe4Vantihypertensive4Vwith4Va4Vsmall4Vsip4Vof4Vwater4V
Withhold4Vthe4Vantihypertensive4Vand4Vadminister4Vit4Vat4Vbedtime
Administer4Vthe4Vmedication4Vby4Vway4Vof4Vthe4Vintravenous4V(IV)4Vroute
Hold4Vthe4Vantihypertensive4Vand4Vresume4Vits4Vadministration4Von4Vthe4Vday4Vafter4
Vthe4VECT4V-
4VANSWERSAdminister4Vthe4Vantihypertensive4Vwith4Va4Vsmall4Vsip4Vof4Vwater4V
Rationale:4VThe4Vnurse4Vshould4Vadminister4Vthe4Vantihypertensive4Vwith4Va4Vsmall4
Vsip4Vof4Vwater.4VGeneral4Vanesthesia4Vis4Vrequired4Vfor4VECT,4Vso4VNPO4Vstatus4Vi
s4Vimposed4Vfor4V64Vto4V84Vhours4Vbefore4Vtreatment4Vto4Vhelp4Vprevent4Vaspiration.
4VExceptions4Vinclude4Vclients4Vwho4Vroutinely4Vreceive4Vcardiac4Vmedications,4Vanti
hypertensive4Vagents,4Vor4Vhistamine4V(H2)4Vblockers,4Vwhich4Vshould4Vbe4Vadminis
tered4Vseveral4Vhours4Vbefore4Vtreatment4Vwith4Va4Vsmall4Vsip4Vof4Vwater.4VWithhold
ing4Vthe4Vantihypertensive4Vand4Vadministering4Vit4Vat4Vbedtime4Vand4Vwithholding4V
the4Vantihypertensive4Vand4Vresuming4Vadministration4Von4Vthe4Vday4Vafter4Vthe4VE
CT4Vare4Vincorrect4Vactions,4Vbecause4Vantihypertensives4Vmust4Vbe4Vadministered4
Von4Vtime;4Votherwise,4Vthe4Vrisk4Vfor4Vrebound4Vhypertension4Vexists.4VThe4Vnurse4
Vwould4Vnot4Vadminister4Va4Vmedication4Vby4Vway4Vof4Va4Vroute4Vthat4Vhas4Vnot4Vbe
en4Vprescribed.
A4Vclient4Vwho4Vrecently4Vunderwent4Vcoronary4Vartery4Vbypass4Vgraft4Vsurgery4Vco
mes4Vto4Vthe4Vprimary4Vhealth4Vcare4Vprovider's4Voffice4Vfor4Va4Vfollow-
up4Vvisit.4VOn4Vassessment,4Vthe4Vclient4Vtells4Vthe4Vnurse4Vthat4Vhe4Vis4Vfeeling4Vd
epressed.4VWhich4Vresponse4Vby4Vthe4Vnurse4Vis4Vtherapeutic?
"Tell4Vme4Vmore4Vabout4Vwhat4Vyou're4Vfeeling."4V
"That's4Va4Vnormal4Vresponse4Vafter4Vthis4Vtype4Vof4Vsurgery."
"It4Vwill4Vtake4Vtime,4Vbut4VI4Vpromise4Vyou,4Vyou4Vwill4Vget4Vover4Vthis4Vdepression."
"Every4Vclient4Vwho4Vhas4Vthis4Vsurgery4Vfeels4Vthe4Vsame4Vway4Vfor4Vabout4Va4Vmo
nth."4V-4VANSWERS"Tell4Vme4Vmore4Vabout4Vwhat4Vyou're4Vfeeling."4V
Rationale:4VThe4Vtherapeutic4Vresponse4Vby4Vthe4Vnurse4Vis,4V"Tell4Vme4Vmore4Vabo
ut4Vwhat4Vyou're4Vfeeling."4VWhen4Va4Vclient4Vexpresses4Vfeelings4Vof4Vdepression,4
Vit4Vis4Vextremely4Vimportant4Vfor4Vthe4Vnurse4Vto4Vfurther4Vexplore4Vthese4Vfeelings4
Vwith4Vthe4Vclient.4VIn4Vstating,4V"This4Vis4Va4Vnormal4Vresponse4Vafter4Vthis4Vtype4Vo
f4Vsurgery"4Vthe4Vnurse4Vprovides4Vfalse4Vreassurance4Vand4Vavoids4Vaddressing4Vt
he4Vclient's4Vfeelings.4V"It4Vwill4Vtake4Vtime,4Vbut4VI4Vpromise4Vyou,4Vyou4Vwill4Vget4V
over4Vthe4Vdepression"4Vis4Valso4Va4Vfalse4Vreassurance,4Vand4Vit4Vdoes4Vnot4Venco
urage4Vthe4Vexpression4Vof4Vfeelings.4V"Every4Vclient4Vwho4Vhas4Vthis4Vsurgery4Vfeel
s4Vthe4Vsame4Vway4Vfor4Vabout4Va4Vmonth"4Vis4Va4Vgeneralization4Vthat4Vavoids4Vthe
4Vclient's4Vfeelings.
, A4Vclient4Vin4Vlabor4Vexperiences4Vspontaneous4Vrupture4Vof4Vthe4Vmembranes.4VTh
e4Vnurse4Vimmediately4Vcounts4Vthe4Vfetal4Vheart4Vrate4V(FHR)4Vfor4V14Vfull4Vminute4
Vand4Vthen4Vchecks4Vthe4Vamniotic4Vfluid.4VThe4Vnurse4Vnotes4Vthat4Vthe4Vfluid4Vis4V
yellow4Vand4Vhas4Va4Vstrong4Vodor.4VWhich4Vaction4Vshould4Vbe4Vthe4Vnurse's4Vprior
ity?
Contact4Vthe4Vprimary4Vhealth4Vcare4Vprovider4V
Document4Vthe4Vfindings
Check4Vthe4Vfluid4Vfor4Vprotein
Continue4Vto4Vmonitor4Vthe4Vclient4Vand4Vthe4VFHR4V-
4VANSWERSContact4Vthe4Vprimary4Vhealth4Vcare4Vprovider4V
Rationale:4VThe4Vpriority4Vaction4Vis4Vfor4Vthe4Vnurse4Vto4Vcontact4Vthe4Vprimary4Vhe
alth4Vcare4Vprovider.4VThe4VFHR4Vis4Vassessed4Vfor4Vat4Vleast4V14Vminute4Vwhen4Vt
he4Vmembranes4Vrupture.4VThe4Vnurse4Valso4Vchecks4Vthe4Vquantity,4Vcolor,4Vand4V
odor4Vof4Vthe4Vamniotic4Vfluid.4VThe4Vfluid4Vshould4Vbe4Vclear4V(often4Vwith4Vbits4Vof4
Vvernix)4Vand4Vhave4Va4Vmild4Vodor.4VFluid4Vwith4Va4Vfoul4Vor4Vstrong4Vodor,4Vcloudy
4Vappearance,4Vor4Vyellow4Vcoloration4Vsuggests4Vchorioamnionitis4Vand4Vwarrants4
Vnotifying4Vthe4Vprimary4Vhealth4Vcare4Vprovider.4VA4Vlarge4Vamount4Vof4Vvernix4Vin4
Vthe4Vfluid4Vsuggests4Vthat4Vthe4Vfetus4Vis4Vpreterm.4VGreenish,4Vmeconium-
stained4Vfluid4Vmay4Vbe4Vseen4Vin4Vcases4Vof4Vpostterm4Vgestation4Vor4Vplacental4Vi
nsufficiency.4VChecking4Vthe4Vfluid4Vfor4Vprotein4Vis4Vnot4Vassociated4Vwith4Vthe4Vdat
a4Vin4Vthe4Vquestion.4VThe4Vnurse4Vwould4Vcontinue4Vto4Vmonitor4Vthe4Vclient4Vand4V
the4VFHR4Vand4Vwould4Vdocument4Vthe4Vfindings.
A4Vnurse4Vhas4Vassisted4Va4Vprimary4Vhealth4Vcare4Vprovider4Vin4Vinserting4Va4Vcent
ral4Vvenous4Vaccess4Vdevice4Vinto4Va4Vclient4Vwith4Va4Vdiagnosis4Vof4Vsevere4Vmaln
utrition4Vwho4Vwill4Vbe4Vreceiving4Vparenteral4Vnutrition4V(PN).4VAfter4Vinsertion4Vof4V
the4Vcatheter4Vwhat4Vdoes4Vthe4Vnurse4Vimmediately4Vdo?
Call4Vthe4Vradiography4Vdepartment4Vto4Vobtain4Va4Vchest4Vx-ray4V
Check4Vthe4Vclient's4Vblood4Vglucose4Vlevel4Vto4Vserve4Vas4Va4Vbaseline4Vmeasurem
ent
Hang4Vthe4Vprescribed4Vbag4Vof4VPN4Vand4Vstart4Vthe4Vinfusion4Vat4Vthe4Vprescribed
4Vrate
Infuse4Vnormal4Vsaline4Vsolution4Vthrough4Vthe4Vcatheter4Vat4Va4Vrate4Vof4V1004VmL/
hr4Vto4Vmaintain4Vpatency4V-
4VANSWERSCall4Vthe4Vradiography4Vdepartment4Vto4Vobtain4Va4Vchest4Vx-ray4V
Rationale:4VThe4Vnurse4Vshould4Vimmediately4Vmake4Varrangements4Vto4Vhave4Va4V
chest4Vx-
ray4Vdone.4VOne4Vmajor4Vcomplication4Vassociated4Vwith4Vcentral4Vvenous4Vcatheter
4Vplacement4Vis4Vpneumothorax,4Vwhich4Vmay4Vresult4Vfrom4Vaccidental4Vpuncture4V
of4Vthe4Vlung.4VAfter4Vthe4Vcatheter4Vhas4Vbeen4Vplaced4Vbut4Vbefore4Vit4Vis4Vused4Vf
or4Vinfusions,4Vits4Vplacement4Vmust4Vbe4Vchecked4Vwith4Van4Vx-
ray.4VHanging4Vthe4Vprescribed4Vbag4Vof4VPN4Vand4Vstarting4Vthe4Vinfusion4Vat4Vthe4
Vprescribed4Vrate4Vand4Vinfusing4Vnormal4Vsaline4Vsolution4Vthrough4Vthe4Vcatheter4
Vat4Va4Vrate4Vof4V1004VmL/hr4Vto4Vmaintain4Vpatency4Vare4Vall4Vincorrect4Vbecause4V
they4Vcould4Vresult4Vin4Vthe4Vinfusion4Vof4Vsolution4Vinto4Va4Vlung4Vif4Va4Vpneumotho