VATI Med Surge Assessment.

Thinning of the skin. Only apply the ointment to dry patches of the skin to avoid atrophy.

Tiamcinolone - Hypopigmentation - Excessive hair growth (hypertrichosis) - Thinning of the skin

Frothy sputum Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately.

- Frothy sputum - Dyspnea - Wheezing Treatment: Fluid restriction & diuretics to decrease preload & pulmonary congestion

- Dependent edma - Jugular distention - Weight gain

Respiratory alkalosis - The pH is alkaline (increased) - PCO2 is decreased representing alveolar hyperventilation & resultant respiratory alkalosis

Osteoporosis Bone become thinner as a result of mineral loss & nitrogen depletion.

A pearly, waxy nodule. - Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy appearance resulting from overexposure to the sun. especially on the face, head, and neck. -A client who has melanoma has a lesion with irregular borders and variegated colors of red, white, and blue, most often on the upper back or lower legs. -A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with a ulcerated center, resulting from sun exposure, chronic irritation, burns, or irradiation to the skin.

Irregular border and varigated colored lesions of red, white, blue. - Most often on the upper back or lower legs

Firm, nodular, and crusty lesion with an ulcerated center from sun exposure, chronic irritation, burns, or irradiation to the skin.

Herpes Zoster - Weeping, blister type lesions.

LOW URINE SPECFIC GRAVITY. -A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity.

- Low specific gravity - Elevated hemoglobin

Remove clutter from rooms and hallways - This allows the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client

- Single date calender - Redirect the client by starting another activity - Use short, simple senteces when explaining an activity - Explanation should be done immediately before an activity

REFRACTORY HYPOXEMIA - A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS.

- Pleural friction rub - Tachypnea - Tachycardia - Dyspnea - Sudden, sharp chest pain

- Trachial deviation - Dyspnea - Tachycardia - Tachypnea - Decreased or absent breath sounds over area

Hemoptysis Bloody expectorant when coughing

USE OF ASSCESSORY MUSCLES. - A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen.

- Labored breathing & wheezing - Distended neck veins - Use of accessory muscle - Bronchodilators - Epinephrine - Corticosteroids - Oxygen

SKIN RASH. - the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately.

- Skin Rash - Bleeding gums - Increased facial hair - Constipation

CLEAR DRAINAGE OF DRESSINGS - This is an indication of a cerebral spinal leak

- Slight elevation in temperature - No more than 125 mL of drainage in 4 hours - Decreased bowel sounds due to anesthesia - Monitor for paralytic ileus

INCREASED ABDOMINAL GIRTH

" I changed the floor plan of our homes to accommodate my father's wheelchair. "

THE CLIENT IS BECOMING FLUSHED. - Flushing is a manifestation of an infusion reaction to vancomycin that also causes a rash on the face and upper body, called red man syndrome. Red man syndrome results from infusing vancomycin to rapidly. The nurse should infuse the medication over at least 60 mins.

Results from infusing vancomycin too rapidly. The nurse should infuse the medication over at least 60 min. - Hypotension - Tachycardia - Ototoxcity - Renal failure - Flushing

BUN 24 mg/dL. - A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity

5,000-10,000

4.7-6.1 million

3.5-5.0

IRON DEFICIENCY ANEMIA. - The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron-deficiency anemia.

The client's daily peak expiratory flow (PEF) measures 85% above personal best. - A client who has asthma should use a peak flow meter twice daily to monitor asthma control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness of medication therapy.

- Anorexia - Iron deficiency anemia - Hypocalcemia - Tachycardia - Rapid gastric emptying - Nausea & abdomnial cramping

" I WILL CHECK MY BLOOD SUGAR LEVEL BEFORE EXCERCISING. " - Clients who have diabetes mellitus should not exercise if their blood glucose level is less than 80 mg/dL or greater than 250 mg/dL. A client who has type 1 diabetes mellitus and is hyperglycemic can experience even higher blood glucose levels. Hypoglycemia can also occur during exercise and up to 24 hr following exercise

ASPIRIN & NAPROXEN. - Aspirin is an antiplatelet medication. It can increase the risk of bleeding when taken with warfarin. - . Naproxen is an NSAID that relieves mild to moderate pain. It can increase the risk of bleeding if taken with warfarin.

PLACE THE CLIENT LEANING FORWARD OVER THE BEDSIDE TABLE FOR THE PROCEDURE. - This allows the provider complete access to the client's chest and back. This position also expands the spaces between the ribs where the pleural fluid accumulates.

- Empty the bladder before the procedure - Weigh the client before and after procedure - Keep the client on bedrest after the procedure

" I will place my used tissues in a plastic bag. " - The sputum of a client who has tuberculosis is considered infectious until there are three consecutive sputum samples that test negative for Mycobacterium tuberculosis. Tissues that are soiled with the client's sputum should be placed in a plastic bag and sealed to avoid spreading the infection

USE DISPOSABLE UTENSILS FOR MEALS. - The client who receives radioactive iodine has radioactivity in the body fluids, including saliva, for several weeks following treatment. The nurse should instruct the client to use disposable utensils, plates, and cups during this time period to decrease the risk for radiation exposure to other members of the household

- Remain 1m (3ft) away from infants, children, and pregnant women. - 1-hour of limited exposure to pregnant women - Use disposable utensils - Condom catheter & drainage bag - Facial tissues in underwear

A PCA PUMP WILL BE USED FOR POSTOPERATIVE PAIN CONTROL. - A PCA pump is a common method of pain management in the first 24 hr following an open radical prostatectomy. The nurse should teach the client how to manage pain during the preoperative period rather than waiting until after surgery when the client is feeling the sedative effects of the anesthesia and pain medication.

ATRIAL FIBRILLATION. - With atrial fibrillation, multiple rapid impulses from many different foci cause depolarization of the atria in a rapid, disorganized manner. This causes a chaotic rhythm on the ECG strip that has no clear P waves, no atrial contractions, and an irregular rhythm.

- Atrial impulses reach the ventricles through the AV node at a slower-than-normal rate. - P waves have a regular shape and appear consistently in front of the QRS complex.

- Regular rhythm - Low HR - Clear P waves that outnumber QRS complexes -

- Rapid, regular rhythm - HR: 140 + - P waves not visible

REPORT CLOUDY DIALYSATE DRAINAGE TO THE PROVIDER. - The most serious complication of peritoneal dialysis is peritonitis, an inflammation of the peritoneum. Assessment findings include cloudy dialysate drainage, rebound abdominal tenderness, and diffuse abdominal pain. The nurse should report these findings immediately to the provider, who can then prescribe a fluid culture, quick exchanges to wash out mediators of infection, and antibiotics.

- Do NOT use infusion pump - Report cloudy dialysate drainage - Warm solution using a heating pad or place in the warming section of cycling machine - Dwell time: 4-8 hours - Drainage: 10-20 minutes

- Elevated WBC count (20,000+) A client who has acute appendicitis will show a moderate elevation of the WBC count from 10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a perforated appendix. - Rebound tenderness (RLQ) A client who has appendicitis develops localized pain over the right lower quadrant of the abdomen. When the area is palpated, pain occurs during release of pressure on the client's abdomen. - Anorexia A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite.

APPLY MOISTURIZER TO DAMP SKIN AFTER BATHING. - Applying a moisturizer to damp skin after bathing helps prevent dry skin. The drier the skin is, the greater the risk is for skin breakdown.

KETONES IN THE URINE - Clients who have type 1 diabetes mellitus can have ketones in the urine, which are a byproduct of the breakdown of fats for energy. Ketones in the urine are an indicator of inadequate amounts of insulin and high blood glucose levels

- Hyponatremia - Increased serum osmolality - Ketone in the urine - Hyperglycemia

ASSESS THE SURGICAL INCISION FOR SIGNS OF INFECTION. - A surgical wound infection typically appears 3 to 6 days following the surgery. Fever from the third postoperative day onward indicates that this client's greatest risk is either a wound infection or a pulmonary infection; therefore, this is the priority action the nurse should take.

"I may have mild cramping for several hours." - The client should expect very little discomfort from the LEEP procedure, which is performed in ambulatory care using a painless electrical current.

A CLIENT WHOSE MEDICATIONS TO MANAGE PARKINSON'S DISEASE ARE NO LONGER EFFECTIVE. - Parkinson's disease is a neurodegenerative disease marked by alterations in mobility, cognition, mood, and functioning of the sympathetic nervous system. The effectiveness of medications used to manage the symptoms can decrease over time. When this occurs, the nurse should make a referral to palliative care. Palliative care is designed to maintain the client's current quality of life through symptom management, assist with decision making regarding care needs, and work with families to identify care outcomes

I WILL KEEP THE MEDICATION REFRIGERATED - The nurse should instruct the client to refrigerate the oral cephalosporin suspension to maintain its full strength until the completion of the medication regimen

PEAKED T WAVES. - Elevated potassium levels result in tall, peaked T waves, flat or absent P waves, prolonged PR intervals, wide QRS complexes, and ectopic beats. Hyperkalemia can progress to complete heart block, ventricular fibrillation, and asystole.

1. Notify the surgeon about the finding. 2. Cover the client's wound with a sterile saline-soaked dressing. 3. Place the client in a low Fowler's position with their knee bent 4. Prepare the client to be transferred to surgery. -Based on evidence based practice, the nurse should immediately contact the surgeon and notify them of the wound eviscerations. The nurse should then cover the clients wound with a sterile saline soaked dressing to protect it from infection. The nurse should then place the client in a low fowlers position with their knees bent and then prepare the client to be transferred to surgery.

VERIFY THAT THE CLIENT HAS ADEQUATE IV ACCESS. - When using the airway, breathing, and circulation approach to client care, the nurse should first verify that the client has at least a 20-gauge IV for the administration of blood.

INCREASED THIRST. - The nurse should teach the client that increased thirst, or polydipsia, is a manifestation of hyperglycemia, which can lead to dehydration. Other manifestations of hyperglycemia include an increase in appetite, or polyphagia, an increase in urine production, or polyuria, and fatigue.

DIABETES MELLITUS. - Diabetes mellitus is a predisposing factor for UTIs. Clients who have underlying diseases that compromise their immune response have an increased risk for UTIs.

ELEVATED TOILET SEAT. - A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet seat should be in place in the client's home prior to the client's discharge.

RETINOPATHY. - Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in the retina, and blindness.

- Coronary Artery Disease - Stroke - Hypertension

MONITOR THE CLIENT FOR ANY ADVERSE REACTIONS. - Although the client is a universal recipient and can receive any ABO blood type, the nurse should continue to monitor for any adverse reactions, which is standard procedure for any blood transfusion.

TURN THE CLIENT BY LOG ROLLING WITH A TURNING SHEET. - The nurse should turn the client by log rolling with a turning sheet to keep the client's back straight and to prevent back spasms from occurring.

AVOID EATING RED MEAT. - A client should not eat red meat for 3 days before collecting the specimen because red meat contains hemoglobin, myoglobin, and some enzymes that can cause a false-positive result in a fecal occult blood test.

- Do not take NSAIDs for 7 days - Do not eat raw vegetables, red meat, or citritus fruits for 3 days before - Do not take Vitamin C supplements for 3 days before

CHECK FOR END-TIDAL CARBON DIOXIDE LEVELS. - According to evidence-based practice, the most reliable method for verifying ET tube placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable method for verifying placement.

INCREASED T4 LEVELS. - Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid stimulating hormone level reflect primary hyperthyroidism.

Avoid food products that contain trans-fat. - A client who receives hemodialysis for chronic kidney disease should avoid foods that contain saturated and trans fats. Healthier fats should be substituted to reduce cardiovascular and dyslipidemia risks.

STOP THE HEPARIN INFUSION FOR 1 HOUR. - According to the titration table, when the aPTT is greater than 95, the nurse should stop the infusion for 1 hr, then restart the infusion with a decrease of 3 units/kg/hr, which is a decrease of 240 units/hr for a client who weighs 80 kg (176.4 lb).

ABGS. - When using the airway, breathing, and circulation (ABC) approach to client care, the nurse's priority assessment is to monitor the client's ABGs, including respiratory status.

PARADOXICAL PULSE. - Cardiac tamponade results from an excess of fluid in the pericardial cavity and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or more on expiration and is a manifestation of cardiac tamponade. The nurse should report manifestations of cardiac tamponade to the provider immediately.

SKIN CHANGES. A client who is receiving radiation therapy to the breast will have localized adverse effects of the treatment, such as skin changes, esophagitis, and lymphedema.

The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services. - Palliative care is an interdisciplinary approach to client care that works toward optimizing the quality of life for a client who has a chronic illness. Nurses advocate for their clients when they promote the health, safety, and rights of the client, such as providing a referral for needed services to relieve suffering and promote a client's quality of life.

- Pink, frothy sputum - Tachypnea - Wheezing A client who has pulmonary edema can develop pink, frothy sputum, wheezing and tachypnea.

MEDICATION IS AVALIABLE THAT WILL REDUCE THE RISK OF HIV TRANSMISSION. - Tenofovir/emtricitabine is an oral medication that can be used prophylactically by a client who does not have an HIV infection to reduce the risk for HIV transmission. Pre-exposure prophylaxis is recommended for men who have sexual relationships with men, clients who are heterosexual and sexually active, noninfected partners who have a sexual relationship with a partner who has HIV, and clients who use intravenous drugs.

INSPECT THE PIN SITES AT LEAST EVERY 8 HOURS. - The nurse should inspect the pin sites at least every 8 hr, noting any inflammation or evidence of infection. Expected findings after the insertion of pins include redness, warmth, and serosanguineous drainage, which should subside after 72 hr.

- Do not apply any ointment to pin sites - Prophylactic broad spectrum IV antibiotic 24-48 hours after insertion - Sterile, absorbent, nonadherent dressing - Inspect pin sites every 8 hours - Cleanse with chlorhexidine solution

PROVIDE FINER FOOD AT MEALTIME. - The nurse should provide the client who has dementia with fingers foods. Clients who have dementia can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.

SURGICAL MASK. - The nurse should adhere to droplet precautions in addition to standard precautions for clients who have bacterial meningitis, provided the causative pathogen spreads via droplets. - The nurse should place these clients in a private room and wear a mask when within 0.9 m (3 feet) of the client to prevent acquiring the infection. - Clients should wear a mask whenever they are outside their room

SURGICAL DRAIN OUTPUT 300 ML DURING AN 8 HOUR SHIFT. - A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit.

CLOSE THE PINCH CLAMP ON THE CVC. - The greatest risk to this client is air embolism resulting from accidental disconnection of the CVC tubing. Therefore, the priority action is to clamp the catheter immediately by closing the pinch clamp to prevent any further air from entering the system. When an air embolism occurs, air enters through the central vein into the right ventricle and lodges by the pulmonary valve, decreasing the amount of blood that is able to enter into the ventricle and the pulmonary arteries.

PLACE MONITORING CORDS & TUBES IN A STOCKINETTE. -The nurse should place monitoring devices in a stockinette to prevent direct contact with the client's skin.

THE STOOL WILL HAVE A HIGH VOLUME OF LIQUID. - The nurse should include in the teaching that when peristalsis returns, the client can have an initial period of high-volume liquid stool output, more than 1,000 mL/day. Later, as the proximal small bowel adapts, stool volume should decrease.

IF MY HEART STARTS RACING, MY PROVIDER MIGHT NEED TO ADJUST MY DOSAGE. - Levothyroxine increases metabolism, which can increase oxygen consumption and heart rate. If the client's heart is racing, the dosage might be too high, causing thyrotoxicosis with manifestations of tachycardia, insomnia, tremors and nervousness, hyperthermia, heat intolerance, and sweating. The provider should retest the client's thyroid hormone levels and adjust the dosage accordingly.

LEFT LOWER QUADRANT. - Diverticula commonly develop in the sigmoid colon because of the high pressure it takes to move stool into the rectum. Therefore, the pain with this disorder is often in the left lower quadrant.

ORAL CONTRACEPTIVES WERE TAKEN FOR THE LAST 6 YEARS. - Clients who take hormones, such as estrogen therapy, fertility drugs, and oral contraceptives, have an increased risk of developing breast cancer.

TAKE PSYLLIUM IN THE EVENING. - A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to increase the bulk of the stool, reduce constipation, and promote regular bowel movements.

Monitor for oral secretion every 2 hours -The nurse should monitor for oral secretion's at least every 2hrs to decrease the likelihood of micro organisms moving from the mouth into the respiratory tract. Provide oral care every 2 hours -The nurse should provide oral care every 2hrs using chlorhexidine rinse or sodium chloride solution with swabbing or tooth brushing. Assess the client daily for readiness of extubation. -To lower the risk of the client acquiring VAP, the nurse should assess the client daily for neurological readiness for discontinuing mechanical ventilation.

ASSESS THE PICC INFUSION SYSTEM SYSTEMATICALLY. The nurse should assess the infusion system in a systematic fashion beginning with the insertion site, observing for signs of infection, and working upward and following the tubing to ensure that all connections are secure.

THE CLIENT HAD A CATARACT SURGERY 1 DAY AGO. - A client who had recent eye surgery is at increased risk for falls. The nurse should ensure the client is wearing prescription glasses when ambulating and that environmental hazards, such as loose rugs, are removed because the client's vision might be blurred.

WALK 30 MIN DAILY AT A COMFORTABLE PACE. - The clients should walk 30 min daily at a comfortable pace to prevent weight gain and decrease the risk of coronary artery disease.

AN IV PUMP IS PLUGGED INTO AN OUTLET NEAR THE SINK. - The nurse should plug all electrical appliances into outlets away from wet areas. Water conducts electricity and places the client at risk for electrocution.

PLACE A SMALL PILLOW UNDER THE HEAD WHILE LYING SUPINE. - The halo fixator device is worn for a period of 8 to 12 weeks and immobilizes the cervical spine, preventing flexion and hyperextension of the neck. The use of a small pillow under the head provides support to the head and neck, preventing additional discomfort and pressure from the device.

" Use water-based lubricant during intercourse to reduce discomfort. " - The nurse should instruct the client to use water-based lubricants to help relieve vaginal dryness and irritation during sexual intercourse. Atrophic vaginitis is a common manifestation of menopause.

-The nurse should assess the medial malleolus ANKLE of a client who has chronic venous insufficiency for the presence of a venous ulcer. The ankle is the most common area for a venous ulcer. a client who has venous insufficiency can exhibit skin discoloration and edema as well as a large or superficial ulcer with irregular borders at the site of the medial or lateral malleolus that weeps exudate. A pulse is palpable in this area and the client typically experiences a moderate level of pain at the site.

a large or superficial ulcer with irregular borders at the ANKLE. - Weeps exudate - Skin discoloration and edema - Palpable pulse - Moderate level of pain at the site.

- Assess the tip and between the toes - Cyanosis - Cool to the touch - Weak or absent pulses

- Assess the ball of the foot - Deep with pale even edges - granulation in the wound bed

ADMINISTER OXYGEN USING A HIGH-CONCENTRATION MASK. - The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to ensure that the client has a patent airway and administer oxygen using a high-concentration mask to promote oxygen perfusion to vital organs.

URINE SPECIFIC GRAVITY 1.020 - The concentration of the urine regulated by hydration is measured by the weight of the particles in the urine. A urine specific gravity within the expected reference range of 1.005 to 1.030 indicates that fluid replacement is keeping up with fluid loss from gastric drainage

RAPID PULSE RATE. - A client who has hypovolemia has a rapid, weak pulse rate to compensate for the decrease in blood volume in an attempt to increase blood pressure.

- Flat neck veins - Rapid pulse rate - Urine output less than 30 mL/hr - High specific gravity - Increased RR

AIRBORNE PRECAUTIONS. - Tuberculosis, like measles, chickenpox, and varicella zoster, spreads by airborne transmission of micro-organisms that suspend in the air for prolonged periods. - The nurse should implement airborne precautions by placing the client in a negative-pressure airflow room and wearing an N95 respirator mask

The nurse should implement contact precautions for clients who have known or suspected infections due to micro-organisms that spread by direct contact or contact with items in the environment, such as C. Diff , vancomycin-resistant enterococci, and MRSA.

The nurse should implement droplet precautions for clients who have known or suspected infections transmitted by droplets that travel up to 0.9 m (3 feet) but do not remain suspended for prolonged periods, such as diphtheria, rubella, mumps, pertussis, and meningococcal pneumonia or sepsis.

The nurse should implement protective environment precautions for clients who have a diminished or dysfunctional neutrophil count. A protective environment is essential for clients who have severe immunosuppression.

RETENTION OF CARBON DIOXIDE. - Retention of carbon dioxide can result from respiratory depression, inadequate chest expansion, airway obstruction, or decreased alveolar capillary diffusion.

A CLIENT WHO HAS A HISTORY OF ASTHMA. - Propranolol is a nonselective beta-adrenergic blocker. Contraindications include asthma, COPD, and heart failure because the blockade of beta2 receptors in the lungs can cause bronchoconstriction.

- I will avoid crowds The client who is immunocompromised should avoid crowds while undergoing chemotherapy to reduce the risk of infection. - I will take my temperature daily. The client who is immunocompromised should take daily temperature reading and report an elevated temp to the provider.

CONSTANT BUBBLING IN THE WATER SEAL CHAMBER. - Constant bubbling in the water seal chamber can be an indication of an air leak, which is caused by a disruption in the system such as a loose connection. Pulmonary air leaks create intermittent bubbling that is synchronous with respiration. This finding should be reported to the provider immediately.

MAINTAIN LOW INTERMITTENT SUCTION. - The nurse should maintain low intermittent suction to prevent gastric irritation and ulceration. With a small bowel obstruction, the NG tube removes gastric secretions and decompresses the bowel.

- Maintain low intermittent suction. - Assess patency & irrigrate the tube every 4 hours - Record gastric ouput every 4 hours - Fasten end of tube to the client's gown

"I am aware that my diabetes is caused by an autoimmune disorder." - Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells. This autoimmune reaction is often triggered by a viral infection.

Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg - A change in blood pressure from 130/80 mm Hg to 180/100 mm Hg indicates a widened pulse pressure and hypertension, which are components of Cushing's triad, a sign of increased intracranial pressure.

"Select desserts such as angel-food cake." Clients who have acute cholelithiasis will be prescribed a low-fat diet. Desserts such as sherbet, gelatin, and angel food cake are dessert choices that are low in fat.

CONSUME A DIET THAT IS HIGH IN CALORIES. - Dyspnea decreases energy available for eating. Therefore, the nurse should encourage the client to eat soft, high-calorie and high-protein foods to prevent weight loss.

CONTACT THE PROVIDER WHO WILL BE PERFORMING THE PROCEDURE. - The nurse should advocate for the client by informing the provider if the client does not understand the procedure. It is the responsibility of the provider to discuss the procedure more fully with the client.

"You will not be able to eat or drink after the procedure until you are able to cough." - A client who had a bronchoscopy received a local anesthetic that can suppress the cough reflex. The cough reflex protects the client from aspirating fluids or food. Therefore, the client should not eat or drink until the cough reflex returns.

MAINTAIN ABDUCTION OF THE AFFECTED EXTREMITY. - The nurse should ensure that the affected extremity is in a position of abduction to prevent hip dislocation. The nurse should place an abductor pillow or several pillows between the client's legs to keep the affected extremity in abduction while the client is in bed.

Run water in the sink prior to toileting. -The nurse should instruct the client to run water prior to toileting. The sound of the running water can trigger the clients urge to urinate.

Massage therapy. -Massage therapy involves manipulating the clients muscles and soft tissue, which improves circulation and promotes relaxation. Massage can decrease pain in clients who have cancer. Light pressure should be applied.

Broccoli -Clients who have cholecystitis should avoid gas=producing foods, which include broccoli and cabbage. The client should also consume a diet high in fiber and low in fat.

A client who has a prealbumin level of 8.6 mg/dL -A client who has a low prealbumin level may be experiencing malnutrition, a risk factor for skin breakdown. The expected reference range of prealbumin is 15-36 mg/dL. Decreased prealbumin levels can also be present in liver damage, burns, and inflammation.