Chapter 7 Blood Collection Equipment, Additives, and Order of Draw
A nurse is caring for a client in the emergency department (ED). Complete the diagram by dragging from the choices below to specify what condition the client is most’likely experiencing, 2 actions the nurse should take Nurses’ Notes Vital Signs to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress. Nurses’ Notes Client comes to the ED with nausea, vomiting, confusion, and tremors. Client is agitated and irritable. Orientated only to self. The client states, Actions to Take 1 Parameters to Monitor 1 “I’m tired of all these people in my house: visiting is over, my mom is dead, and I need to rest before the funeral.” Potential Condition The client’s partner states the client’s mother died 6 years ago. The Actions to Take 2 Parameters to Monitor 2 client’s partner states that the client has been drinking “a lot” for the past 6 months. The client agreed to stop drinking 2 days ago. The partner believes that the client’s last drink was roughly 36 hr ago. Actions to Take Potential Condition Parameters to Monitor Administer Bipolar disorder Manipulative lorazepam. behavior Assist client with Depression Dull affect self-care and personal hygiene. Fluid and Pad the client’s Neglect electrolyte status side rails. Report to the Alcohol Serotonin appropriate withdrawal syndrome mandated agency syndrome
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