Use active listening skills to seek information from the client.
Encourage the client to describe the problem as she sees it.
Ask the client to tell you exactly what she thinks is happening.
Tell the client that she is delusional and you can help her.
Explain to the client that most people are not investigated by the CIA.
Reassure the client that you are not with the CIA.
Position the client directly on the trochanter when side lying.
Avoid use of donut type devices.
Massage bony prominences.
Elevate the HOB no more than 30 degrees when possible.
When the client is side lying, use the 30 degree lateral inclined position.
Avoid uninterrupted sitting in a chair or wheelchair.
Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect.
Determine whether the client has any sudden loss of vision accompanied by pain.
Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision.
Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved.
Have the client demonstrate the use of eye drops.
Assess the client for chronic diseases such as diabetes.
Warming the dialysate
Too rapid installation
Infiltration of the solution into the bloodstream
Accumulation of dialysate solution under the diaphragm
Too rapid outflow of the dialysate.
Serum potassium level decreases from 5.4 to 4.6 mEq/L
Cr decreases from 1.6 to 0.8 mg/dL
Gb increases from 10-12 g/dL
WBC increase from 5000 to 8000/mm^3
BUN decreases from 110 to 90 mg/dL
BUN 18 mg/dL
K 5.2 mEq/L
Decreased creatinine clearance.
Cr 5.0 mg/dL
Decrease in pulse rate in affected leg.
Paresthesia distal to area of injury.
Toes on affected leg cool to touch and edematous.
Complaints that pins are hurting.
Complaints of leg pain unrelieved by analgesics or repositioning.
Client angry and calling loudly to the nurse every ten minutes.
Elevate the HOB.
Decrease intake of caffeine.
Discuss strategies for weight loss if overweight.
Increase fluid intake with meals.
Take ranitidine (Zantac) at hs.
Eat a bedtime snack of milk and protein.
Verify consent has been signed.
Explain procedure to client.
Provide clear liquid. no caffeine diet.
Evaluate peripheral pulses.
Obtain a 12 lead ECG
Obtain history of shellfish allergy.
Presence of cardiac pain.
Medications taken before hospitalizations.
Presence of jugular vein distention.
Heart sounds and apical rate.
Presence of diaphoresis.
History of difficulty breathing.
Dressings do not need to be changed frequently because there is minimal drainage.
Healing will be facilitated by wearing leg compression devices.
When the client is in sitting position, he should keep his legs elevated.
Avoid standing for long periods of time.
Cool packs can be applied to the ulcers to decrease inflammation.
Soak the affected extremity in warm water every evening.
A task approach method is used to provide care to clients.
Managed care concepts and tools are used when providing client care.
Nursing staff are led by a nurse when providing care to a group of clients.
A single registered nurse is responsible for providing nursing care to a group of clients.
A client who requires wound irrigation
A client who requires frequent ambulation
A client who is receiving continuous tube feedings
A client who requires frequent vital signs after a cardiac catheterization
Failure to replace body fluids
Increased risk of hypotension
Failure to teach the client adequately
Increased need to protect the client
Excessive bumetanide administration
Lack of follow-up nursing actions