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Blood pressure of 100/70 mm Hg may suggest fluid overload, a component of pulmonary edema, but it’s not a specific indicator for furosemide use. This finding reflects systemic effects rather than direct lung involvement. Furosemide targets fluid in the alveoli, not just blood pressure changes. Without lung-specific signs like crackles, this alone doesn’t confirm the need for the diuretic, as hypotension could also indicate other issues unrelated to pulmonary edema’s primary pathology.

Vesicular breath sounds are soft, normal sounds heard over healthy lung fields, indicating no fluid accumulation. Pulmonary edema, however, presents with abnormal sounds like crackles due to fluid in alveoli. Furosemide is prescribed to clear this fluid, so normal vesicular sounds suggest the lungs are clear, not requiring diuretic intervention. This finding contradicts the condition furosemide treats, making it an inappropriate indicator for the prescription in this context.

Potassium at 3.2 mEq/L is below normal (3.5-5.0 mEq/L), often a side effect of furosemide due to increased urinary potassium loss. However, this isn’t an indication for starting the drug; it’s a consequence to monitor post-administration. Pulmonary edema’s treatment focuses on fluid removal, not electrolyte levels initially. Low potassium might require correction, but it doesn’t justify the prescription, making this finding unrelated to furosemide’s therapeutic intent.

Limiting reconciliation to admission and discharge misses medication changes during hospitalization, risking errors or omissions. Effective reconciliation occurs at all care transitions—admission, transfers, discharge—ensuring a current, accurate list. This approach prevents discrepancies, like duplicative therapies or missed doses, that could harm the client. Skipping interim updates undermines safety, as hospital regimens evolve, making this action incomplete and inadequate for proper care.

Comparing only home medications to new prescriptions excludes drugs given during hospitalization, creating an incomplete profile. Reconciliation requires reviewing all medications—home, inpatient, and discharge—to identify conflicts or redundancies. Focusing solely on prescribed home meds overlooks real-time additions, like painkillers or antibiotics, risking interactions or therapeutic gaps. This narrow scope fails to meet reconciliation’s comprehensive safety goal.

Deleting new prescriptions with potential home medication interactions exceeds nursing scope and risks altering treatment without provider input. Reconciliation identifies conflicts for collaborative resolution, not unilateral changes. For example, removing a necessary anticoagulant due to an interaction could harm the client. This action bypasses clinical judgment, undermining the process’s intent to flag, not fix, issues independently.

Removing weights during repositioning disrupts skeletal traction’s constant pull, risking fracture misalignment or delayed healing. Traction maintains bone stability via weights and pulleys, essential for immobilization. Lifting the client without weights negates this, potentially shifting the fracture site. This action contradicts traction principles, compromising treatment efficacy and patient outcomes, making it unsafe and incorrect.

Cleansing pin sites with hydrogen peroxide damages healthy tissue and delays healing by disrupting granulation, despite its antiseptic properties. Sterile saline or chlorhexidine is preferred, preserving skin integrity around traction pins. This outdated practice increases infection risk ironically, as tissue breakdown invites pathogens. It’s not aligned with current evidence-based care, rendering it inappropriate.

Checking ropes every 8 hours ensures traction equipment integrity, preventing sudden weight drops that could misalign the fracture. While important, it’s secondary to infection monitoring, as fraying is less immediate than sepsis risk. Daily pin checks address a more urgent threat to healing. This action, though useful, isn’t the top priority here.

Administering a rectal suppository risks rectal mucosal tearing in thrombocytopenia, where low platelets hinder clot formation, potentially causing significant bleeding. Chemotherapy-induced bone marrow suppression heightens this danger, making invasive procedures contraindicated. Safer alternatives, like oral medications, avoid this hazard. This action contradicts standard care, increasing harm in a client already prone to hemorrhage.

A low-residue diet reduces bowel bulk, easing digestion, but doesn’t address thrombocytopenia’s bleeding risk, the primary concern here. It’s used in conditions like diverticulitis, not for platelet issues. Chemotherapy-related bleeding stems from vessel integrity, not diet, so this action lacks relevance. It fails to mitigate the client’s key vulnerability, making it inappropriate.

Encouraging a safety razor in thrombocytopenia heightens bleeding risk, as even minor skin nicks won’t clot properly with low platelets from chemotherapy. Electric razors are recommended instead, minimizing cuts. This advice endangers the client, opposing bleeding precautions critical for safety. It ignores the condition’s pathophysiology, where external trauma must be avoided to prevent uncontrolled bleeding.

Glucosamine, derived from shellfish, supports cartilage repair in osteoarthritis by aiding glycosaminoglycan synthesis, not affecting cholesterol pathways. It lacks lipid-lowering properties, focusing on joint health instead. For a client with high cholesterol, this supplement offers no benefit to lipid profiles, rendering it irrelevant to the goal of reducing levels.

Cranberry tablets inhibit bacterial adhesion in the urinary tract, preventing infections, but have no impact on cholesterol metabolism or lipid levels. Their anthocyanins benefit bladder health, not cardiovascular risk factors. In high cholesterol, this supplement doesn’t address the condition, making it an ineffective choice for this client’s needs.

Ginkgo biloba enhances cerebral blood flow via vasodilation, potentially aiding memory, but it doesn’t alter cholesterol synthesis or clearance. Its antioxidants target circulation, not lipids directly. For a client with high cholesterol, this supplement lacks evidence of lowering levels, failing to meet the therapeutic aim here.

A parent with type 2 diabetes indicates a genetic risk for metabolic issues, possibly relevant to liver disease progression, like NAFLD. However, it’s historical data, not an immediate threat to transplant success. The priority lies with factors affecting post-operative care, like adherence, over family history. This statement, while useful, isn’t urgent for reporting now.

Childhood asthma history suggests past respiratory issues, potentially complicating anesthesia or recovery, but if resolved, it’s low priority. End-stage liver disease focuses on hepatic function, not dormant lung conditions. Without current symptoms, this doesn’t impact transplant candidacy urgently, making it less critical than adherence concerns.

Lack of family support affects emotional coping and post-transplant care logistics, potentially stressing recovery, but it’s not an immediate medical risk. Adherence to medications directly impacts survival, outweighing psychosocial factors in urgency. This statement, while relevant, doesn’t necessitate urgent reporting compared to compliance issues.

Infusing 0.9% sodium chloride at 150 mL/hr through an arterial line is excessive and dangerous, risking fluid overload or vessel damage. Arterial lines use a slow flush (1-3 mL/hr) to maintain patency, not high-volume infusion. This rate suits IV hydration, not arterial monitoring, making it an incorrect and harmful action for this setup.

Having the client bear down (Valsalva maneuver) increases intrathoracic pressure, falsely elevating arterial readings, distorting accuracy. Arterial lines provide continuous, real-time pressure via transducers, not manual checks requiring such actions. This technique applies to venous lines or respiratory tests, not arterial monitoring, rendering it inappropriate and misleading here.

Aligning the transducer to the radial artery level is incorrect; it should be at the phlebostatic axis (heart level) for accurate pressure readings. Radial alignment overestimates pressure due to gravitational effects, skewing data. Proper calibration at the heart ensures true arterial values, so this action fails to meet monitoring standards.