A nurse is planning care for a client who was recently admitted to the medical-surgical unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
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Related Questions
Correct Answer is C
Explanation
A. To prevent infection and ensure proper healing, it's usually advised to avoid submerging the catheterization site in water until it has adequately healed.
B. There is generally no need for a special diet such as a clear liquid diet following cardiac catheterization unless specified for other reasons.
C. Following cardiac catheterization, it's important to keep the pressure dressing in place to ensure proper healing and prevent bleeding from the catheterization site. Typically, the dressing is removed the next day under safe, controlled conditions.
D. Typically, children can return to school within a few days after cardiac catheterization unless complications arise or there are other specific medical advisories.
Correct Answer is C
Explanation
A: Attaching the restraint to the bed's side rails can increase the risk of injury if the client tries to climb over them. The restraints should instead be attached to be bed frame.
B: Restraints should be removed at least every 2 hours to assess the client's condition and provide necessary care, not every 4 hours.
C: Documentation of the client's condition is essential to ensure proper monitoring and assessment while the restraint is in use.
D: PRN restraint prescriptions should not be used for clients who are aggressive; restraints should only be used as a last resort and with a clear medical justification.
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