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Alkalosis occurs when the blood pH is higher than the normal range, specifically above 7.45. This condition indicates that the blood is too alkaline. Causes of alkalosis can include hyperventilation, loss of stomach acid through vomiting, or an overuse of diuretics. Since a blood pH of 7.21 is below the normal range, it does not indicate alkalosis.

The normal pH range for blood is between 7.35 and 7.45. This range is crucial for the body’s metabolic processes and enzyme functions. A blood pH of 7.21 is below this range, indicating an abnormal condition.

Hyperkalemia refers to an elevated level of potassium in the blood, not a change in blood pH. While hyperkalemia can be associated with acidosis, it is not defined by the pH level itself. Therefore, a blood pH of 7.21 does not directly indicate hyperkalemia.

Monitoring the CXR (chest X-ray) results is not directly related to assessing myelosuppression. A chest X-ray is typically used to evaluate the lungs and heart, and while it can help identify infections or other complications, it does not provide information about bone marrow activity or blood cell counts. Myelosuppression specifically affects the production of blood cells in the bone marrow, which is best assessed through blood tests like the CBC (Complete Blood Count).

Monitoring the BMP (Basic Metabolic Panel), especially the sodium, potassium, and magnesium counts, is important for evaluating electrolyte balance and kidney function. However, it does not directly assess myelosuppression. Myelosuppression involves the suppression of bone marrow activity, leading to decreased production of blood cells, which is not reflected in electrolyte levels.

Monitoring the spinal fluid analysis is not relevant for assessing myelosuppression. Spinal fluid analysis is typically used to diagnose conditions affecting the central nervous system, such as infections, bleeding, or multiple sclerosis. It does not provide information about bone marrow activity or blood cell counts, which are the primary concerns in myelosuppression.

Review the patient’s medication list to verify its accuracy and completeness. They also compare the list of current medications with new orders or prescriptions to detect any discrepancies or potential issues.
While this choice describes an important aspect of medication reconciliation, it is not as comprehensive as Choice A. Verifying the accuracy and completeness of the medication list and comparing it with new orders or prescriptions is a critical step in identifying discrepancies or potential issues. However, it does not encompass the initial gathering of information from various sources or the documentation process, which are essential components of medication reconciliation.

Review the medication history provided by the patient and make changes in the medications based on the patient’s current health status. They communicate any medication changes to the patient and the healthcare team.
This choice focuses on reviewing the medication history and making changes based on the patient’s current health status. While this is an important aspect of patient care, it does not fully capture the scope of medication reconciliation. Medication reconciliation involves not only reviewing and updating medications but also gathering comprehensive information from multiple sources and ensuring accurate documentation. This choice lacks the emphasis on verification and documentation that is central to the medication reconciliation process.

While demonstrating a caring attitude is an essential aspect of nursing, it is not the primary goal of pain assessment. A caring attitude helps build trust and rapport with patients and their families, which is crucial for effective communication and overall patient care. However, the main objective of pain assessment is to gather data that will inform pain management strategies.

Ensuring complete documentation in the Electronic Health Record (EHR) is important for maintaining accurate patient records and facilitating communication among healthcare providers. However, this is a secondary goal that supports the primary objective of pain assessment. The main focus of pain assessment is to collect data that will guide pain management interventions.

Developing a therapeutic relationship with the patient is an important aspect of nursing care, as it fosters trust and open communication. However, it is not the primary goal of pain assessment. The main objective of pain assessment is to gather data that will inform pain management strategies. A therapeutic relationship can enhance the effectiveness of pain assessment and management, but it is a means to an end rather than the end itself.

3% Saline is a hypertonic solution, meaning it has a higher concentration of solutes compared to the blood plasma. It is typically used in critical care settings for specific conditions such as severe hyponatremia or cerebral edema. Administering 3% Saline to a patient with a fluid deficit who requires isotonic fluid replacement would not be appropriate because it could lead to cellular dehydration and other complications due to its high osmolarity.

Saline 0.45%, also known as half-normal saline, is a hypotonic solution. It has a lower concentration of solutes compared to blood plasma and is used to treat patients with hypernatremia or those who need to be rehydrated without adding too much sodium. However, it is not suitable for isotonic fluid replacement because it can cause cells to swell and potentially burst due to the influx of water into the cells.

Dextrose 10% is a hypertonic solution used primarily for providing calories in patients who need parenteral nutrition or for treating severe hypoglycemia. It is not suitable for isotonic fluid replacement because its high glucose content can lead to osmotic diuresis and fluid shifts that are not desirable in patients needing isotonic fluids.

While heat can aid in the healing process by improving blood flow and nutrient delivery to the injured area, it does not specifically increase the rate of the muscle remodeling process. Muscle remodeling involves complex cellular activities that are not solely influenced by external heat application.

Heat therapy is generally not used to reduce inflammation. In fact, applying heat to an inflamed area can sometimes exacerbate the inflammation. Cold therapy is more effective for reducing inflammation, especially in the initial stages of an injury.

Heat therapy does not numb pain signals in the same way that cold therapy does. Cold therapy works by numbing the affected area and reducing nerve activity, which helps to alleviate pain. Heat therapy, on the other hand, works by improving circulation and relaxing muscles.

Applying wrist restraints to secure IV lines should not be the first action. Restraints are generally considered a last resort due to their potential to cause harm and distress. They should only be used when absolutely necessary and after other interventions have failed. In this scenario, the patient’s agitation and confusion could be due to hypoxia, and addressing the underlying cause is more important than immediately resorting to restraints.

Administering the prescribed opioid is not the first action to take. While pain management is crucial, opioids can sometimes exacerbate confusion and agitation, especially in the immediate postoperative period. It is essential to first assess the patient’s vital signs and oxygen levels to rule out hypoxia or other complications before administering any medication.

Taking the blood pressure and pulse is important but not the immediate first action. While these vital signs provide critical information about the patient’s cardiovascular status, checking the oxygen saturation is more urgent in this context. Hypoxia can lead to agitation and confusion, and addressing it promptly can stabilize the patient more effectively.

Masking is generally used when there is a risk of exposure to respiratory droplets, such as when a patient has a known or suspected respiratory infection. However, it is not typically required for a standard health history interview unless there is a specific risk of exposure to infectious agents.

Goggles or face shields are used when there is a risk of splashes or sprays of blood, body fluids, secretions, or excretions. Helping a patient to ambulate in the hall does not typically involve such risks, so goggles are not usually required in this scenario.

Gowns are used to protect skin and clothing from contamination when there is a risk of exposure to infectious material. Delivering a food tray to a patient does not generally pose such a risk, so gowning is not necessary for this task under standard precautions.

Giving the patient a pamphlet that reinforces teaching done by the nurse is a task that can be delegated to assistive personnel (AP). This action does not require clinical judgment or advanced skills. The pamphlet serves as a supplementary resource to the verbal and hands-on education provided by the nurse. It is a straightforward task that AP can perform, ensuring that the patient has access to written information that reinforces the nurse’s teaching.

Evaluating whether the patient and caregiver understand the teaching is a critical component of the discharge process that requires the clinical judgment of a licensed nurse. This task involves assessing the patient’s and caregiver’s comprehension, identifying any gaps in understanding, and providing additional education as needed. It is not appropriate to delegate this responsibility to assistive personnel (AP) because it requires professional assessment skills.

Planning topics for the discharge teaching session with the patient and caregiver involves developing a comprehensive and individualized teaching plan based on the patient’s specific needs and condition. This task requires the expertise and clinical judgment of a licensed nurse to ensure that all relevant topics are covered and that the teaching plan is tailored to the patient’s situation. Delegating this task to assistive personnel (AP) is not appropriate because it requires advanced planning and professional knowledge.