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statistics for nursing a practical approach
Fundamentals Of Nursing: Standards And Practices 2nd Edition Sue C. DeLaune, Patricia Kelly Ladner - Solutions
2. Ensures accuracy in identification of medication.
1. Prevents the occurrence of hypersensitivity reactions.
17. Observe the patient for side effects for 30 minutes after administration.Rationale
16. Record on the MAR the drug given, number of drops instilled, and nostril medicated.
15. Remove gloves and wash hands.
14. Return the client to a comfortable position and provide the client with the emesis basin and tissue to expectorate any medication that flows into the oropharynx and mouth.
13. Discard any unused medication remaining in the bottle.
12. Instruct the client to remain supine for 5 minutes.
11. Insert the nasal drops about 3/8 inch into nostril, keeping the tip of the dropper away from the sides of the nares. Instill the prescribed dosage of medication and observe the client for signs of discomfort.
10. Squeeze some medication into the dropper.
9. Instruct the client to breathe through his or her mouth.
8. Place the client in a supine position and hyperextend the neck. Position the head to the site that facilitates the drops’ reaching the expected site, as shown in Figure 29-36.
7. Explain that the client may feel a burning sensation to the mucosa or a choking sensation, or both, as the drop trickles back into the throat.
6. Instruct client to blow nose unless contraindicated by client condition (such as recent nosebleed).
5. Explain the procedure to the client and provide privacy.
4. Check client’s identification armband.
3. Wash hands.
2. Check the MAR against health care practitioner’s written order.
1. Check with the client and chart for any known allergies.
14. Assess for potential problems related to the medications administered.
13. Provides documentation of the administration.
12. Decreases the transmission of microorganisms.
11. Ensures that all medications have been taken.
Medication that falls on floor is contaminated.
Prevents contamination of the medication;single-pill administration assists swallowing and helps prevent aspiration.
14. Observe the client for side effects or adverse reactions.Rationale 10. Facilitates downward movement of the medication in digestive system and helps absorption.
13. Record the administered medications on the MAR.
12. Wash your hands.
11. Remain with the client until all medications have been swallowed.
If a medication falls on the floor, discard the pill and start over.
If the client is unable to hold the medication cup, assist the client by using the medication cup to introduce the pills to the person’s mouth one at a time.
10. Offer liquids before and during ingestion;encourage the patient to drink 5–6 oz of water.
9. Prevents aspiration and promotes swallowing of the medication.
8. Provides data to determine if the medication should be given.
7. Encourages client cooperation and increases client awareness of what to expect from the medication.
6. Ensures right client.
Prevents spillage.
Promotes efficiency and decreases risk of error.
Ensures right dose, route, and time.
Prevents soiling and maintains legibility of the label. Ensures accurate measurement.
Decreases possibility of contaminating the medication and helps ensure accuracy.
Determines the correct amount of medication to be given.
Increases accuracy and reduces chance of error.
5. Ensures that the right client receives the right medications.
4. Decreases transmission of microorganisms.
3. Decreases risk of allergic reactions such as hives, urticaria, or anaphylactic shock.
9. Assist client to a sitting position.Rationale
8. Perform any assessment required before the administration (such as apical pulse rate before administration of digoxin.)
7. Identify the drug for the client and its therapeutic purpose.
6. Check client’s armband before administering the medications.
Place on the tray or medication cart.
Check MAR to make sure all medications to be administered have been prepared.
Recheck medications prepared with MAR.
Prepare liquids by placing the label side of the medicine bottle against the palm of your hand and pouring the liquid at eye level(Figure 29-8). Liquids should be measured at fluid level at the surface or the meniscus not the edges.
Avoid touching the drug while pouring in cup. If unit-dose is available leave drug in the wrapper until at the bedside.
Calculate the medication dose, if necessary.Double-check calculations for accuracy.
Select the correct medication and doublecheck against MAR.
5. Prepare the medications for one client at a time:
4. Wash your hands.
3. Check for drug allergies.
2. Ensures accuracy in the administration of the medication.
1. Decreases the risk of aspiration.
2. Check the MAR against the health care practitioner’s written orders.Rationale
1. Assess the client for potential problems (e.g., absence of a gag reflex).
12. Develop teaching guidelines for clients regarding medication in the home.
11. Discuss potential liabilities for the nurse administering medications.
10. Correctly explain procedures for the different methods of medication administration including the choice of route and site.
9. Discuss principles of safe medication administration including the five rights of medication administration.
8. Correctly calculate appropriate dosage for medications as prescribed.
7. Differentiate between allergic reaction, side effects, toxic effect, and idiosyncratic reaction to medications.
6. Identify the responsibilities of the nurse for each type of medication order.
5. Describe the factors that can affect a drug’s action.
4. Explain the principles of pharmacokinetics, including absorption, distribution, and metabolism, and excretion of drugs.
3. Discuss the nurse’s legal responsibilities in preparation and administration of medications.
2. Describe the influence of drug standards and legislation on medication administration.
1. Define the key terms and abbreviations frequently used in medication administration.
12. Select interventions, based on the functional health pattern(s) affecting the results, when planning nursing care for your assigned clients.
11. Relate the laboratory and diagnostic tests to the functional health patterns. Consider the special diagnostic teaching needs for each of the functional health patterns.
10. Plan the postprocedural care for a cardiac catheterization client using the protocol for care of the client after diagnostic testing.
9. What specific teaching should be done for a client undergoing arteriography? Evaluate the need for teaching based on the procedure. Refer to the protocol on preparing the client for diagnostic testing for appropriate teaching interventions.
8. You are counseling Maria Rodriguez regarding the symptoms and risk factors of large radiation exposures.She is receiving radiation therapy for breast cancer. Where in her medical record should the potential risk factors be addressed?
7. Which client is more at risk for coronary heart disease? Mrs. Smith, a 59-year-old who is postmenopausal with a cholesterol of 185 mg/dl, LDL of 131 mg/dl, HDL of 25 mg/dl, and triglycerides of 250 mg/dl. Mr. Jones, a 55-year-old who smokes occasionally with a cholesterol of 220 mg/dl, LDL of
6. What are the physiological effects of acetylcholine on the nervous system? Why should the practitioner be notified about a decreased level of cholinesterase for a client scheduled to receive succinylcholine for either major surgery or electroconvulsive therapy?
5. If your blood type is AB positive, what are the possible blood types of your parents? Can you receive Rh-negative blood? Explain your answer.
4. What is a normal prothrombin time (PT)? PT is a comparative test that measures the client’s PT to the control time. Both the PT and control time results are reported. One example of the use of a PT is to measure the effectiveness of prescribed anticoagulant therapy. In this case, the
3. Explain how the three sources of venipuncture variability can cause inaccurate laboratory results.
2. With invasive procedures the body is entered with some type of instrumentation; there is a puncture site.If you fall down and a nail pierces your leg, you have a puncture site. What are you at risk for immediately after the incidence and 48 to 72 hours postinjury?Can you relate the body’s
1. In reference to the nursing tip about Mr. Simon, what did his history and physical reveal? Why did the nurse practitioner order a white blood cell differential as opposed to a white blood cell count?What do you think Mr. Simon’s medical diagnosis will be: an infected ingrown toenail, anemia,
Who transported the client to another area (designate the names of persons who provided transport and place of destination)
Any symptoms of complications
Vital signs and other assessment data, such as client’s tolerance of the procedure or pain/discomfort level
Type of specimen obtained and where it was delivered
Type of anesthesia, dye, or other medications administered
Reason for the procedure
Who performed the procedure
Explain what to report to the nurse during the immediate recovery phase.Documentation Record in the client’s medical record:
Explain what to expect during the immediate recovery phase.
Answer questions and concerns of the client or family member.
Explain what occurred during the procedure.
4. Discuss nursing interventions for the common diagnostic procedures.
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