A nurse is caring for a client who has heart failure.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing 

dropdown

and 

dropdown

D. An oral airway is a device used to maintain a patent airway by preventing the tongue from obstructing the throat. It can be useful during or after a seizure to ensure the client can breathe effectively and to prevent airway obstruction due to tongue relaxation or loss of muscle tone.

A Wrist restraints are used to immobilize a client's wrists and are not typically indicated for seizure management. Restraining a client during a seizure can increase the risk of injury and hinder appropriate assessment and care

B. Nasogastric (NG) tubes are used for enteral feeding, medication administration, or gastric decompression. They are not directly related to managing seizures and are not typically required during or after a seizure episode. Therefore, an NG tube is not necessary in the client's room for seizure management.

C. Tongue blades are used to depress the tongue for examination of the mouth and throat, but they are not recommended during or immediately after a seizure. There is a common misconception that placing a tongue blade in the mouth prevents the tongue from being bitten during a seizure, but this can actually cause more harm, such as injury to the teeth or gums, during involuntary movements.

Obtain client weight twice daily

Anticipated: This intervention is anticipated. Monitoring the client's weight is crucial when they are receiving Total Parenteral Nutrition (TPN) to assess for fluid status, nutritional adequacy, and response to therapy. It helps in adjusting TPN rates and managing fluid balance.

Have 3 nurses verify the TPN solution prescription

Anticipated: Verifying TPN solution prescription by multiple nurses is a critical safety measure to prevent errors in TPN administration, which can have serious consequences. This ensures that the TPN solution matches the prescribed order in terms of content, concentration, and rate.

Request a prescription for insulin

Anticipated: Given the client's hyperglycemia (fasting blood glucose of 140 mg/dL) and potential exacerbation by TPN administration (which can be rich in glucose), requesting insulin is appropriate. Insulin helps manage blood glucose levels and prevent hyperglycemia, especially important in clients with diabetes or those on TPN.

Request an antibiotic to be administered

Anticipated: The client presents with signs of infection (fever, productive cough, yellow sputum) and crackles auscultated in the lungs, indicating a possible respiratory infection. Requesting antibiotics is essential to treat the infection promptly and prevent further complications.

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula

Nonessential: The client is currently receiving 2 L/min oxygen via nasal cannula with an oxygen saturation of 90%. Decreasing the oxygen flow may compromise oxygenation further, especially given the crackles and productive cough. It is more appropriate to maintain or potentially increase oxygen support based on the client's oxygen saturation.

Notify provider to increase TPN rate/hr

Contraindicated: The client has diarrhea (3 episodes in the past 4 hours) and an abdominal distension, which may indicate gastrointestinal intolerance to TPN. Increasing the TPN rate could exacerbate diarrhea and worsen fluid and electrolyte imbalances. It is important to address the underlying cause of diarrhea and abdominal symptoms before considering any increase in TPN rate.