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Protect the Patient

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Protect the Patient

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Protecting the Patient

Created by

RNPRPEPBESTIE
RNPRPEPBESTIE
United States

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Protect the PatientOnline version

Protecting the Patient

by RNPRPEPBESTIE
1

A client admitted for treatment of a lower extremity DVT is receiving continuous anticoagulant therapy through a central line . During assessment the nurse notes the client is more fatigued than earlier , has new ecchymosis along the flank , and reports a dull persistent headache . Blood pressure is slightly lower than baseline and heart rate has increased compared with the previous shift . The nurse reviews the morning lab results and recognizes that the priority nursing action is to .

2

A client receiving vesicant chemotherapy through a peripheral IV begins to report a burning sensation at the insertion site midway through the infusion . The nurse observes slight swelling and notes the infusion pump has alarmed twice for increased pressure . Blood return was present earlier but is now difficult to obtain . The nurse understands that safe care at this time requires .

3

A client receiving chemotherapy for leukemia reports increased fatigue and gum tenderness during morning care . The nurse notes new petechiae on the lower legs and a small amount of bleeding after the client rinses the mouth . Vital signs are BP 94 / 58 , HR 108 , RR 18 , Temp 99 . 1°F . Morning labs show platelet count 24 , 000 / mm³ ? , Hgb 8 . 2 g / dL ? , WBC 3 , 100 / mm³ ? . The nurse recognizes that safe nursing care requires .

4

A client receiving vesicant chemotherapy through a peripheral IV reports a sudden burning sensation at the site shortly after the infusion begins . The nurse observes mild swelling and blanching around the insertion area . The infusion pump alarms for occlusion and blood return is no longer present . Vital signs remain stable and the client denies shortness of breath . The nurse recognizes that safe nursing care requires .

5

A client receiving long - term anticoagulant therapy following valve replacement returns to the clinic for follow - up . The client reports frequent minor nosebleeds and states plans to begin a new high - intensity exercise program . Assessment reveals scattered ecchymosis on the upper arms . Vital signs are BP 110 / 68 , HR 92 , RR 18 . Laboratory results show INR slightly above the therapeutic range compared with the previous visit . The nurse recognizes that safe patient teaching requires .

6

A client with advanced metastatic cancer receiving palliative care reports increasing shortness of breath while resting in bed . The nurse observes shallow respirations and use of accessory muscles . Vital signs are BP 98 / 60 , HR 110 , RR 26 , SpO ? 89% on room air . Lung sounds are diminished at the bases and the client appears anxious but remains alert . The nurse recognizes that safe nursing care requires .

7

A client receiving long - term chemotherapy through an implanted port is admitted for scheduled treatment . At the beginning of the shift the client denies pain or discomfort and vital signs are stable . The previous nurse documents successful infusion during the night . Before preparing the next medication , the nurse reviews the care plan and understands that safe nursing practice requires .

8

A client receiving radiation therapy for head and neck cancer reports increasing mouth soreness and difficulty swallowing solid foods . The nurse observes mild erythema and small ulcerations along the oral mucosa . Vital signs are BP 112 / 70 , HR 90 , RR 18 , Temp 99 . 2°F . The client states eating has become tiring and fluid intake has decreased since yesterday . The nurse recognizes that safe nursing care requires .

 
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