Ask frequently if the client understands the instructions.
Ask an interpreter to relay the instructions to the client.
Write out the instructions and have a family member read them to the client.
Demostrate the procedure to the client and have the client return the demonstration.
A client with late-stage acquired immunodeficiency syndrome (AIDS).
A client with left-side paralysis after a cerebrovascular accident (CVA).
A client who is undergoing treatment for heroin addiction.
A client who had coronary artery bypass surgery 2 weeks ago.
Identify one way to increase social interaction
Report increased adaptation to changes in health status.
Identify at least one factor contributing to altered sexuality patterns.
Return a demonstration of measures that can increase independence
Small decubitus ulcer noted on left leg.
Seems to be mad at the doctor.
Client had a good day.
Skin moist and cool.
Edematous lower leg
Purulent wound drainage
Decreased cardiac output
Ineffective breathing pattern
Altered renal tissue perfusion
Clean from the center out in a circular
Remove the drain before cleansing the skin.
Clean briskly around the site with alcohol.
Wear sterile gloves and a mask.
Reposition the client every 2 hours
Restrict fluids to 1,000 ml in 24 hours.
Administer oxygen by cannula as ordered.
Keep the head of the bed at a 30-degree angle.
Liquid or semi-liquid stools
Hard, brown formed stools
Loss of urge to defecate
Body image disturbance
Altered sexuality pattern
Ineffective individual coping
Use the pump as is because the medication is ordered STAT.
Obtain another pump from central supply for the infusion
Tape the broken ground to the plug and use the pump.
Report the broken prong to the supervisor.
Aspirate urine from the tubing port using a sterile syringe and needle.
Disconnect the catheter from the tubing and obtain urine.
Open the drainage bag and pour out some urine.
Wear sterile gloves when obtaining urine.
Fluid volume excess
Toileting self-care deficit
Fluid volume excess
Toileting self-care deficit
High risk for injury
Sleep pattern disturbance
Elevate the head of the bed.
Position the client on the left side.
Warm the formula before administering it.
Hang a full day's worth of formula at one time.
Fresh orange slices
Ground beef patties
Administer the injection as prescribed
Call the physician and request an oral pain medication.
Withhold the injection until the client understands its importance
Explain that no other medication can be given until the client takes the injection.
Assess the client's temperature every 8 hours.
Place the client in respiratory isolation
Monitor the client's fluid intake and output.
Wear gloves during all client contact
Notify the Cancer Society of the client's diagnosis.
Request Meals On Wheels to provide adequate nutrition intake.
Refer the client to a home health nurse for follow-up visits to provide colostomy care.
Ask an occupational therapist to evaluate the client at home.
Prolong hospitalization until the client can function independently.
Teach the client how to perform self-care.
Provide the financial resources needed to ensure proper care.
Prevent the need for further medical follow-up.
Serum sodium level of 135 mEq/liter
Temperature of 99.6oF (37.5oC)
Neck vein distention
Dark amber urine
Notify the physician.
Discontinue the infusion.
Administer the prescribed diuretic.
Slow the infusion and notify the physician.
Instruct the client to cough
Ask the client to extend the tongue.
Tickle the uvula with a tongue blade
Observe while the client swallows sips of water.
Arm and leg weakness.
Absence of gag reflex.
Difficulty with swallowing.
Inability to speak clearly.
Standards of Nursing Practice
Patient's Bill of Rights
Nurse Practice Act
Code for Nurses
Altered role performance
Impaired physical mobility
Obtain an order for a tranquilizer.
Limit visitors to 15 minutes per day.
Encourage the client to verbalize feelings
Reinforce the client's responsibility to the family.
Do you need anything now?
Why do you think you had a heart attack?
What were you doing when the pain started?
Has anyone in your family been sick lately?
Wear gloves whenever in contact with the client.
Consider all body substances potentially infectious.
Place a body substance isolation sign on the client's door.
Wear a gown and gloves when caring for a client in respiratory isolation.
Instruct the client to notify the nurse if itching, swelling, or dyspnea occurs.
Inform the client that the transfusion usually takes 1 1/2 to 2 hours.
Document the blood administration in the client care record.
Assess the client's vital signs when the transfusion is completed
The skin is released before the needle is withdrawn.
The deltoid muscle is the preferred site for administration.
Aspiration is not necessary because the needle is inserted deep in the muscle layer.
The needle remains in place for 10 seconds after injection to allow the medication to disperse.
Monitor urine output every hour.
Infuse I.V. fluids at 83 ml/hour
Administer oxygen by nasal cannula at 3 liters/minute
Draw specimens for hemoglobin and hematocrit every 6 hours.
Apply a tourniquet below the chosen vein site
Inspect the IV solution for particles or contamination
Secure an armboard to the joint located above the IV site
Place a cool compress over the vein
Presence of bowel sounds
Serum protein levels
Daily calorie counts
Daily intake and output
Stop the TPN
Decrease the flow rate of the TPN
Notify the physician
"What is your normal body temperature?"
"Do you experience frequent infections?"
"Do you have a family history of problems with general anesthesia?"
"Have you ever suffered from heat exhaustion or heat stroke?"
Obtain a temperature to monitor for infection
Monitor the blood pressure (BP) to assess for fluid volume overload
Label the dressing with the date and time of catheter insertion
Prepare the client for a chest x-ray examination
Uncompensated metabolic alkalosis
Compensated metabolic acidosis
Uncompensated respiratory acidosis
Compensated respiratory alkalosis
Sodium of 145 mEq/L
Magnesium 2.0 mEq /L
Potassium 5.2 mEq/L
. Phosphorus 2.3 mEq/L
Is isotonic with the plasma and other body fluids
Is hypotonic with the plasma and other body fluids
Does not affect the plasma osmolarity
Is the same solution as sodium chloride 0.9%