VATI REMEDIATION WEEK 3

The nurse is caring for a client post-craniotomy to treat a brain tumor. What postoperative nursing actions should the nurse initiate? The nurse should administer medications as ordered regarding risks and complications of seizures, increased intracranial pressure and monitor neurologic status. The medications used include manitol and dexamethasone, and phenytoin or diazepam for the seizures. The nurse should additionally initiate a consult to Occupation, speech, and physical therapy as needed. Social services should also be offer for assistance in case management, family and rehab. A hospitalized client with a sealed radioactive implant asks the nurse, “can my family visit me?” What education should the nurse provide regarding visitors? The clients family runs risk of lead contamination and poisoning so, the nurse should assure the client that they may receive visitors but under limitations and instruction. The client and visitors should understand that they can only visit x 30 minutes, they should refrain at 6 feet from source, and they cannot visit if they are under 16 years old, pregnant or trying to conceive. A client with Alzheimer’s Disease is being discharged home. What teaching should the nurse provide to the client and the caregiver regarding home safety measures? The nurse should educate the client and caregiver to ensure safety at home by doing the following: - remove scatter rugs - install door locks and alarms - provide good lighting and hand rails on stairs - mark steps with colored tape - place mattresses on floor - remove clutter from halls - place shower chair in the tub - keep cleaning supplies in locked cupboards - enrolls in safe return home program - participate in exercise program to maintain mobility The nurse is assessing a client with a left-sided stroke. What clinical manifestations can the nurse anticipate? The left cerebral hemisphere is respoinsible for language, math skills and analytical thinking- these may be clinically shown affected by : - expressive or receptive aphasia - agnosia (cannot recognize familiar objects) - alexia ( reading difficulty) - aragphia (writing difficulty) - right extremity weakness or paralysis - slow cautious behavior - depression, anger, frustration - visual changes ( hemianopsia) - A nurse is caring for a client who has had a below the knee amputation of his right leg due to traumatic injury. Discuss (3) potential postoperative complications that can develop and the nursing interventions to address the complication. Flexion contractures – RN should encourage range of motion exercises and if allowed by surgeon, elevate residual limb for the first 24-48 hours. Also have the client lay prone for 20-30 min several times a day Infection- Nurse should palpate residual limb for warmth. Heat can indicate infection, compare pulses with other extremity, and administer antibiotics. Pain- administers analgesics as allowed. Identify phantom from incisional pain. Calcitonin, beta blockers, antiepileptics may decrease phantom limb pain. The nurse is preparing to administer epoetin alfa to a client with dhronic kidney disease (CKD). What laboratory values will be most important to monitor? Epoiten Alfa stimulates production of RBC’s so you want to get a CBC lab. With CKD you also monitor BUN, Creatnine, and blood electrolytes. The nurse is monitoring a client who is receiving a blood transfusion of packed RBCs. Describe the clinical manifestations of an acute hemolytic transfusion reaction and what nursing actions should be done if this type of reaction occurs.