The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question?
a. Enoxaparin (Lovenox) 40 mg subcutane-ous twice daily
b. Transfusion of 2 units of fresh frozen plasma
c. Regular insulin intravenous drip per pro-tocol
d. Cefazolin (Ancef) 1 g IV every 6 hours
A
Therapy during the second (late) phase of septic shock is aimed at enhancing the blood's ability to clot. Enoxaparin would increase the client's risk of bleeding and therefore should not be ad-ministered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client's blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.
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A newly diagnosed type I, insulin-dependent diabetic with good blood sugar control is at 20 weeks' gestation. She asks the nurse how her diabetes will affect her baby. The best explanation would include:
1. "Your baby may be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3. "As long as you control your blood sugar, your baby will not be affected at all." 4. "Your baby might have high blood sugar for several days."
The home care nurse plans the environment of the client with Parkinson's disease. Which of the following should the environment include?
A) Brightly colored throw rugs B) Electric adjustable bed with side rails C) Weight training bench and weights D) Shower with nonslip surface and rails
Which intervention strategy would the community psychiatric nurse include when planning care for
a mentally ill client being cared for in the community? a. Enforce boundaries by way of seclusion. b. Develop a long-term relationship. c. Administer prescribed medication three times daily. d. Provide three nutritious meals with snacks between meals.
A nurse plans the interventions to prepare a patient for a bone marrow aspiration. (Place the options in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.)
a. Assist the patient to lie on his or her abdomen and drape the hip and lower limbs. b. Confirm the presence of laboratory personnel to stain the specimen. c. Apply a pressure dressing and help the patient lie on his or her back. d. Ensure that a signed permission form is obtained. e. Explain that the procedure will take about 30 minutes.