Take and document the client’s vital signs every hour.
Assess the client’s dressings every two (2) hours.
Check the client’s urinary output every shift.
Maintain the client’s blood pressure greater than 100/60.
The client vomited 40 mL on the day shift.
The client has an adequate oral intake, and IV fluids are not needed.
The client has had 6,800 mL intake and 1,350 mL output in the last 24 hours.
The client does not like to have to keep the urine for measurement.
Weigh the client before and after each treatment.
Discuss the recommended fluid restriction.
Provide potato chips or pretzels as a snack.
Monitor the hemodialysis access site continuously.
Keep up a lively conversation during the treatments.
Multivitamin with iron.
Teach the client to wipe from front to back after voiding.
Encourage the client to drink cranberry juice each morning.
Inform the client that frequent episodes of incontinence are expected.
Discuss the signs and symptoms of a recurrent infection.
Have the client fill a container of water to sip until at least 2,000 mL is consumed.
Request that the client sit in a tub of warm water twice a day for 25 minutes.
A 4-ounce grilled chicken breast, broccoli, and small glass of unsweet tea.
Baked potato with chopped ham and sour cream, 12-ounce steak, and beer.
Double patty cheeseburger, french fries, and saccharin sweet Kool Aid.
Roast beef sandwich, potato chips, and soft drink.
Ask the client to provide a clean voided midstream urine for culture.
Insert an 18-gauge peripheral IV catheter and start normal saline fluids.
Arrange for the client to be admitted to the medical unit.
Initiate the ordered intravenous antibiotic medication.
Notify the health-care provider (HCP).
Hang the IVPB antibiotic at the prescribed rate.
Check the laboratory work to determine if the urine culture has been completed.
Increase the normal saline IV fluids from keep open to 150 mL/hour on the IV pump.
Notify the health care provider.
Call a rapid response team (RRT).
Determine the telemetry monitor reading.
Push the Code Blue button.
“Do you have the money to buy your medication?”
“Does the medication give unwanted side effects?”
“Did you quit taking the medications because you don’t feel bad?”
“Can you tell me why you stopped taking the medication?”
Monitor the client’s blood pressure and apical rate every four (4) hours.
Place the client on intake and output every shift.
Require the client to sleep with the head of the bed elevated.
Teach the patient to perform Buerger Allen exercises daily.
Determine if the client is on an antiplatelet or anticoagulant medication.
Assess the client’s neurological status every shift and prn.
The client has a large abdomen and a positive tympanic wave.
The client has paroxysmal nocturnal dyspnea.
The client has 2+ glucose in the urine.
The client has a comorbid condition of myocardial infarction.
Carry your nitroglycerin tablets in a brown bottle.
Swallow a nitroglycerin tablet at the first signof angina.
If one nitroglycerin tablet does not work in 10 minutes, take another.
Nitroglycerin tablets have a fruity odor if they are potent.
Call a Code Blue.
Assess the telemetry reading.
Take the client’s apical pulse.
Have the client sit down.
Take the client’s apical pulse and blood pressure.
Prepare to administer amiodarone IVPB.
Continue to monitor.
Place oxygen on the client via a nasal cannula.
Mix the medication in 100 mL of fluid and administer rapidly.
Push the amiodarone directly into the nearest IV port and raise the arm.
Question the physician’s order because it is not ACLS recommended.
Administer via an IV pump based on mg/kg/min.
Notify the health care provider (HCP).
Assess what the client ate at the last meal.
Request a STAT 12 lead electrocardiogram.
Administer furosemide IVP.
Furosemide IVP to a client with a potassiumlevel of 3.6 mEq/L.
Digoxin orally to a client diagnosed withrapid atrial fibrillation.
Enalapril orally to a client whose BP is 86/64and apical pulse is 65.
Morphine IVP to a client complaining ofchest pain and who is diaphoretic.
Sleep, rest, activity.
Request a dietary consult for a sodium-restricted diet.
Instruct the client to elevate the feet duringthe day.
Teach the client to weigh every morningwearing the same type of clothing.
Assess for edema in dependent areas of thebody.
Encourage the client to drink at least3,000 mL of fluid per day.
Have the client repeat back instructions to thenurse.
Instruct the unlicensed assistive personnel (UAP) to check the client.
Go to the client’s room and assess the client personally.
Have the monitor tech check the client using a different lead.
Call for the Code Blue team and perform cardiopulmonary resuscitation.
Perform a “down and dirty” assessment on each client soon after receiving report.
Determine which client should have a bath and inform the unlicensed assistive personnel.
Give all the clients a wet wash to wash the face and a toothbrush and toothpaste.
Pick up any paper on the floor and get the room ready for morning physician rounds.
The client diagnosed with coronary artery disease complaining of severe indigestion.
The client diagnosed with congestive heart failure who has 3+ pitting edema.
The client diagnosed with atrial fibrillation whose apical rate is 110 and irregular.
The client diagnosed with sinus bradycardia who is complaining of being constipated.