The nurse is caring for an ambulatory client who requires ...

[jparksx]

The nurse is caring for an ambulatory client who requires treatment for pernicious anemia on a medical unit. The client is weak and short of breath, and recently has become confused.
 
  Vital signs at rest are temperature 98.0F, pulse 98 BPM, respirations 22/minute, blood pressure 96/60, and pulse oximetry 95. Which nursing diagnosis has the highest priority?
  1. Confusion, Acute related to aging, and abnormal vital signs
  2. Falls, Risk for related to confusion, weakness, and unfamiliar environment
  3. Knowledge, Deficient (anemia treatment) related to a new medical diagnosis and its treatment
  4. Walking, Impaired related to weakness, low blood pressure, and fast heart rate

Question 2

The client and nurse have set a goal that the client will demonstrate proper technique for self-administration of epoetin alfa (Epogen) before the client is discharged from the hospital.
 
  Which client actions would the nurse evaluate as indicating this goal is met?
  Standard Text: Select all that apply.
  1. The client shakes the vial prior to drawing up the medication.
  2. The client warms the vial by holding it for a few minutes before drawing up the medication.
  3. The client draws the appropriate amount of medication into the syringe.
  4. The client saves the remaining medication in the vial for the next dose.
  5. The client verbalizes a plan to keep the medication vials in a cabinet out of the reach of children.

[Joc]

Answer to Question 1

Correct Answer: 2
Rationale 1: The client has new-onset confusion, which is not a normal outcome of aging. The confusion is related to decreased oxygen supply to the brain. This is not the priority nursing diagnosis.
Rationale 2: High risk for falls is the priority because the client is accustomed to being ambulatory but can move around less safely now due to weakness and confusion.
Rationale 3: The client does need education about the condition and its treatment. The early phase of treatment is not an optimal time to teach, because confusion impairs learning.
Rationale 4: The client's walking is impaired, but this is not the priority nursing diagnosis.
Global Rationale: High risk for falls is the priority because the client is accustomed to being ambulatory but can move around less safely now due to weakness and confusion. The client has new-onset confusion, which is not a normal outcome of aging. The confusion is related to decreased oxygen supply to the brain. This is not the priority nursing diagnosis. The client has new-onset confusion, which is not a normal outcome of aging. The confusion is related to decreased oxygen supply to the brain. This is not the priority nursing diagnosis. The client does need education about the condition and its treatment. The early phase of treatment is not an optimal time to teach, because confusion impairs learning. The client's walking is impaired, but this is not the priority nursing diagnosis.

Answer to Question 2

Correct Answer: 2,3
Rationale 1: The vial should be gently rotated, never shaken, to mix the contents.
Rationale 2: The medication should be warmed. A good method for warming medication is to hold the vial in the hand for a few minutes.
Rationale 3: The client must be accurate in drawing up the medication.
Rationale 4: Vials are for one-time use only, and remaining medication should be discarded.
Rationale 5: While all medications should be kept out of the reach of children, Epogen must be refrigerated.
Global Rationale: The medication should be warmed. A good method for warming medication is to hold the vial in the hand for a few minutes. The client must be accurate in drawing up the medication. The vial should be gently rotated, never shaken, to mix the contents. Vials are for one-time use only, and remaining medication should be discarded. While all medications should be kept out of the reach of children, Epogen must be refrigerated.

[jparksx]

Gracias!

[shailee]

TYSM