Share This Link

Apply pressure dressings to prevent contractures and scarring: Pressure dressings are not used for preventing contractures or scarring after mastectomy. Scar management involves massage therapy or silicone sheets.

Monitor areas at high risk for pressure sores (heels, sacrum, back of the head): Monitoring for pressure sores is essential in general post-operative care but not specifically for mastectomy recovery. Pressure sores are more of a concern when patients are immobile for long periods.

Use compression dressings for up to 4-6 months to increase mobility and reduce scarring: Compression dressings are primarily used to manage swelling and prevent lymphedema after mastectomy. They do not directly help with mobility or range of motion.

Febrile: Febrile reactions are characterized by fever and chills, often due to cytokine release or an immune response. The symptoms here, especially cardiovascular changes, point to circulatory overload rather than a febrile response.

Bacteria: Bacterial contamination of blood products causes sepsis, usually with fever, chills, and signs of infection. The symptoms described are more indicative of circulatory overload than an infection.

Transfusion-related acute lung injury (TRALI): TRALI causes acute respiratory distress and hypoxia, without significant blood pressure changes. The signs of circulatory overload, including elevated blood pressure, suggest this is not TRALI.

Weight loss: Weight loss is not a common side effect of tamoxifen. While some patients may experience changes in appetite or weight, tamoxifen is more often associated with weight gain due to hormonal changes.

Hypertension: While tamoxifen has various hormonal effects, it is not associated with significant changes in blood pressure. Other factors, such as age or underlying conditions, may contribute more to hypertension, not tamoxifen itself.

Muscle cramps: Muscle cramps are a possible side effect of tamoxifen, but they are less common compared to symptoms, such as hot flashes. While cramps can occur, they are not one of the most frequently reported side effects.

If fatigue occurs, stop taking beta blockers: Fatigue can be a common side effect of beta blockers, but the nurse should not recommend stopping the medication without consulting the healthcare provider. Abruptly discontinuing beta blockers can worsen symptoms.

Limit fluid intake to 1000 mL per day: Limiting fluid intake to 1000 mL per day is not a standard for hypertrophic cardiomyopathy unless signs of fluid retention are present. Fluid restriction should be based on the client’s condition and any co-existing issues like heart failure.

Monitor weights daily: Monitoring daily weights is important for assessing fluid retention, but it is not the most crucial teaching point for hypertrophic cardiomyopathy. The primary concern is managing symptoms and avoiding strenuous activity.

Morphine 5 mg IV every 3 hours prn for pain: Morphine is commonly used for pain management in burn patients, as burns are extremely painful. Administering morphine every 3 hours as needed is an appropriate prescription for managing moderate pain in burn patients.

Strict intake and output: Monitoring strict intake and output is a critical part of managing fluid balance in burn patients. It helps ensure that the patient is receiving and excreting the correct volume of fluids, which is crucial for avoiding fluid overload or dehydration.

Insert an indwelling (Foley) catheter: In major burns, inserting a Foley catheter is standard practice. It allows for accurate monitoring of urinary output, which is an essential part of fluid management and kidney function monitoring.

Prevent platelet aggregation: Tissue plasminogen activator does not prevent platelet aggregation; it works by breaking down fibrin, the key component of blood clots. Medications like clopidogrel are more commonly used to prevent platelet aggregation.

Reduce the risk of blood vessel spasm: t-PA is not used to reduce blood vessel spasm. Its primary action is to dissolve blood clots that are blocking blood flow in the brain. Medications like calcium channel blockers are used to manage vasospasm.

Prevent infection in the brain: t-PA is not intended to prevent infection. It is a thrombolytic agent used to dissolve clots, not to treat infections. Infection prevention in stroke patients involves other strategies, like maintaining aseptic techniques during procedures.