Exhibits

The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

a) Denies cramps, weakness, or nausea

This finding indicates that the actions taken were effective in relieving the patient's symptoms of fatigue, weakness, muscle cramps, and nausea. These symptoms may have been caused by electrolyte imbalances, dehydration, or infection related to her ESRD and missed dialysis sessions.

b) BP 116/68 mm Hg, HR 75 bpm

This finding indicates that the actions taken were effective in lowering the patient's blood pressure and heart rate. The patient had a history of HTN and CAD and presented with elevated BP and HR in the ED. The orders for EKG, cardiac monitor, chest X-ray, and echocardiogram may have helped to assess and manage her cardiac status. The patient may have also received antihypertensive medications or fluids as part of her treatment.

c) Potassium level 3.6 mEq/L (3.6 mmol/L)

This finding indicates that the actions taken were effective in normalizing the patient's potassium level. The patient had ESRD and missed dialysis sessions, which could have resulted in hyperkalemia or hypokalemia. The orders for basic metabolic panel and blood cultures may have helped to monitor and correct her electrolyte levels. The patient may have also received potassium supplements or binders as part of her treatment.

d) Verbalizes commitment to dialysis appointments

This finding indicates that the actions taken were effective in educating and motivating the patient to adhere to her dialysis schedule. The patient had ESRD and missed dialysis sessions, which could have worsened her condition and increased her risk of complications. The orders for CT scan of abdomen and echocardiogram may have helped to evaluate her renal function and cardiac function. The patient may have also received counseling or support from the health care team as part of her treatment.

e) Client states that she will need to resume her Lisinopril to control blood pressure

This finding indicates that the actions taken were ineffective in teaching the patient about her medication regimen. The patient had a history of HTN and CAD and was prescribed Lisinopril as an antihypertensive medication. However, Lisinopril is contraindicated in patients with ESRD as it can cause hyperkalemia or worsen renal function. The patient should be informed about the potential risks of taking Lisinopril and advised to consult with her nephrologist or primary care provider before resuming it.

f) Client is eager to add dark green vegetables and potatoes to her diet

This finding indicates that the actions taken were ineffective in educating the patient about her dietary restrictions. The patient had ESRD and required hemodialysis three times a week. She should follow a renal diet that limits the intake of potassium, phosphorus, sodium, and fluid. Dark green vegetables and potatoes are high in potassium and phosphorus and should be avoided or consumed in moderation by patients with ESRD. The patient should be provided with a list of foods that are suitable for her condition and referred to a dietitian for further guidance.

Choice A reason: Place the client in a room near the elevator: This does **not** promote client safety, because it exposes the client to more noise and disturbance, which can increase stress and blood pressure. A quiet and calm environment is preferable for stroke clients.

Choice B reason: Complete a swallow study before giving anything by mouth: This **promotes** client safety, because it assesses the client's ability to swallow and prevent aspiration. Stroke clients may have impaired swallowing due to facial weakness or sensory loss.

Choice C reason: Provide a call button kept within reach: This **promotes** client safety, because it allows the client to communicate their needs and request assistance when needed. Stroke clients may have limited mobility or vision, which can increase their risk of falls or injuries.

Choice D reason: Initiate use of the bed alarm: This **promotes** client safety, because it alerts the staff if the client tries to get out of bed without assistance. Stroke clients may have impaired judgment or balance, which can lead to falls or accidents.

Choice E reason: Place client belongings out of reach: This does **not** promote client safety, because it makes the client feel frustrated and helpless. Stroke clients may have difficulty reaching for their belongings due to hemiparesis or hemiplegia, which can affect their self-care and independence. The nurse should place the client's belongings within reach on their unaffected side and encourage them to use them as much as possible.

Choice F reason: Instruct the client to call before getting up: This **promotes** client safety, because it ensures that the client has adequate support and supervision when getting up. Stroke clients may have orthostatic hypotension, which can cause dizziness or fainting when changing positions. The nurse should assist the client to get up slowly and monitor their vital signs.