A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.
Assess temperature frequently.
Provide diversional activities.
Check circulation every 15-30 minutes.
Socialize with other patients once a shift.
Prevent stress ulcer
Block prostaglandin synthesis
Facilitate protein synthesis.
Enhance gas exchange
Increase the I.V. fluid infusion rate
Irrigate the indwelling urinary catheter
Notify the physician
Continue to monitor and record hourly urine output
“My ankle looks less swollen now”.
“My ankle feels warm”.
“My ankle appears redder now”.
“I need something stronger for pain relief”
Have condescending trust and confidence in their subordinates.
Gives economic and ego awards.
Communicates downward to staffs.
Allows decision making among subordinates.
Provides continuous, coordinated and comprehensive nursing services.
One-to-one nurse patient ratio.
Emphasize the use of group collaboration.
Concentrates on tasks and activities.
Standard written order
Loss of urge to defecate
Hard, brown, formed stools
Liquid or semi-liquid stools
Pulling the lobule down and back
Pulling the helix up and forward
Pulling the helix up and back
Pulling the lobule down and forward
Excessive fetal activity.
Larger than normal uterus for gestational age.
Elevated levels of human chorionic gonadotropin.
Urinary output 90 cc in 2 hours.
Absent patellar reflexes.
Rapid respiratory rate above 40/min.
Rapid rise in blood pressure.
Presenting part is 2 cm above the plane of the ischial spines.
Biparietal diameter is at the level of the ischial spines.
Presenting part in 2 cm below the plane of the ischial spines.
Biparietal diameter is 2 cm above the ischial spines.
Contractions every 1 ½ minutes lasting 70-80 seconds.
Maternal temperature 101.2
Early decelerations in the fetal heart rate.
Fetal heart rate baseline 140-160 bpm.
First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive.
First and second caesareans were for cephalopelvic disproportion.
First caesarean through a classic incision as a result of severe fetal distress.
First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.
Talk to the mother first and then to the toddler.
Bring extra help so it can be done quickly.
Encourage the mother to hold the child.
Ignore the crying and screaming.
Avoid touching the suture line, even when cleaning.
Place the baby in prone position.
Give the baby a pacifier.
Place the infant’s arms in soft elbow restraints.
Feed the infant when he cries.
Allow the infant to rest before feeding.
Bathe the infant and administer medications before feeding.
Weigh and bathe the infant before feeding.
Skim milk and baby food.
Whole milk and baby food.
Iron-rich formula only.
Iron-rich formula and baby food.
Call for help and note the time.
Clear the airway
Give two sharp thumps to the precordium, and check the pulse.
Administer two quick blows.
Plan care so the client can receive 8 hours of uninterrupted sleep each night.
Monitor vital signs every 2 hours.
Make sure that the client takes food and medications at prescribed intervals.
Provide milk every 2 to 3 hours.
Stop the I.V. infusion of heparin and notify the physician.
Continue treatment as ordered.
Expect the warfarin to increase the PTT.
Increase the dosage, because the level is lower than normal.
24 hours later, when edema has subsided.
In the operating room.
After the ileostomy begin to function.
When the client is able to begin self-care procedures.
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