Exhibits

The nurse reviews the nurse's notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Body System

Circulatory

• Heart rate 96 beats/minute
• Blood pressure 90/62 mm Hg
• IV infusing at 125 ml/hr
• Respirations 16 breaths/minute

Respiratory

• Oxygen saturation of 89%
• Several deep breaths

Integumentary

• Episiotomy intact with no redness
• Pad is saturated with blood
• 18 gauge IV to left forearm

Genital/Urinary

• Boggy fundus 1 cm above umbilicus
• Fundus rotated to the right
• Voided 200 mL of clear yellow urine

Rationale

A. This instruction is relevant because alcohol, particularly beer and wine, can exacerbate gout symptoms due to their purine content, which can lead to increased uric acid levels in the blood. High uric acid levels can contribute to gouty arthritis flare-ups.

B. This instruction promotes a healthier dietary choice, as carbonated drinks often contain added sugars and contribute to excess calorie intake, which can contribute to obesity. However, fruit juices can also be high in sugars and should be consumed in moderation. Encouraging water as the primary beverage choice would be even better for weight loss and overall health.

C. This instruction is generally beneficial for maintaining joint mobility and preventing stiffness, which can be particularly important for someone experiencing pain in a weight-bearing joint like the ankle. However, if the pain is severe and acute, active range of motion exercises may need to be introduced gradually and under guidance to avoid exacerbating the condition.

D. Heat therapy can provide symptomatic relief for joint pain associated with conditions like gouty arthritis. However, it is important to ensure that heat is not applied during acute inflammation or gout flare-ups, as it can potentially worsen symptoms. Cold therapy may be more appropriate during active inflammation.

A. Clonazepam is a benzodiazepine used primarily for anxiety disorders and can affect mental status, including cognition and level of alertness. Regular assessment helps monitor for any changes in mental status, such as drowsiness, confusion, or sedation, which are potential side effects of clonazepam.
B. This intervention helps maintain oral hygiene, which is important when a client is taking medications orally. Benzodiazepines like clonazepam can cause dry mouth as a side effect, which can contribute to oral hygiene issues such as increased risk of dental caries or oral infections.
C. Clonazepam itself does not directly affect calcium levels. Monitoring calcium levels is not a routine nursing intervention specifically related to clonazepam administration. This option is not appropriate in this context.
D. Clonazepam is not an opioid and does not directly interact with opioids in a way that would necessitate having an opioid agonist at the bedside. This option is not relevant for a client starting clonazepam.
E. Clonazepam can cause dizziness and impair coordination, especially when starting the medication or with dose changes. Assisting the client to the bathroom helps prevent falls and ensures safety, particularly if the client experiences dizziness or sedation.
F. Benzodiazepines like clonazepam can cause hypotension (low blood pressure), which may exacerbate upon standing (orthostatic hypotension). Screening involves checking blood pressure and heart rate in different positions (lying, sitting, standing) to detect orthostatic changes. This is important to prevent falls and other complications.