Nursing 211

N211: Health Differences Across the Lifespan I 72. Cyanotic nail beds, decreased urinary output, and cool skin a. Rationale: These data indicate cardiogenic shock as an effect of the inadequate output of the heart following a myocardial infarction. 73. Ventricular tachycardia 74. Instructing the patient to avoid exercises after eating a. Rationale: This task is considered patient education, and should not be delegated. 75. Smooth muscle relaxation 76. Hypokalemia a. Rationale: Lasix depletes potassium, and has the potential to cause hypokalemia. The addition of digoxin makes assessment of potassium balance especially important because of the risk of digoxin toxicity. 77. Document the finding 78. To prolong exhalation and increase airway pressure during expiration a. Rationale: Pursed-lip breathing slows (prolongs) exhalation and builds the patient’s ability to control rate and depth of respiration. 79. Able to breath spontaneously without assistance 80. Relaxation therapy 81. Flat chest a. Rationale: Paradoxical chest movement with breathing difficulty results from movement of a detached rib segment (flail segment) 82. There is sensitivity to the tuberculosis bacillus 83. Respiration rate of 18 breaths per minute 84. Respiratory acidosis a. Rationale: The combination of pH<7.4 and PaCO2>40 indicates respiratory acidosis. 85. Discontinue infusion if uncontrolled bleeding occurs. 86. Airway patency 87. There is fluid in the suction chamber 88. Renal a. Rationale: Gentamicin sulfate, an aminoglycoside, has a number of serious side effects. The toxic effect on the renal system is of special concern if the patient is an older adult. 89. Alternative communication methods 90. Swelling of the bronchial lining and filling of the bronchi with mucus. 91. Sits up straight for the test a. Rationale: Correct use of a peak expiratory flow meter requires the patient to stand up 92. Monitor cardiovascular status by assessing cardiac enzymes. 93. Applies suction for no longer than 10 seconds while withdrawing the catheter 94. Fever, tachypnea, cough, and crackles 95. Mental confusion 96. High-Fowler’s with the arms supported on pillows 97. Continuous bubbling in the water-seal chambe

©2012

Page 148

of 148

Achieve