AVPU - ANS Alert, responsive to voice, responsive to pain, unresponsive
Glasgow coma scale - ANS Eye opening, verbal response, motor response, low score 3 highest
score 15
Use of the Glasgow scale is to - ANS Determine neurologic status
Insertion of an NG tube - ANS Determine if the client has a deviated septum, the nurse will need
to insert the tube through the nares of the unobstructed side
Review the laboratory value prior to preparing the medication - ANS When administering a dose
of (Lasix), furosemide
Furosemide - ANS A loop diuretic can lead to hypokalemia
Thyroidectomy - ANS Greatest risk to the client after thyroidectomy is hypocalcemia
Highest priority after thyroidectomy - ANS Tingling around the mouth
Side effects to albuterol(Proventil) - ANS Tremors
Clinical manifestations to a possible latex allergy - ANS Rhinorrhea, nasal irritation
Continuous tube feeding and administering digoxin ( Lanoxin) - ANS Flush the tubing before
and after administration of the medication with 30 ml of water
When a client is experiencing severe anxiety - ANS Speak to the client using simple sentences
A client that has diabetes mellitus and reports having influenza. - ANS Tell client to drink at least
240 ml of sugar free fluids every hour to prevent dehydration
Transdermal fentanyl patch ( Duragesic). Highest priority finding - ANS Difficulty waking the
client
Greatest risk to client receiving transdermal patch - ANS Sadation and respiratory depression
Transdermal fentanyl patch - ANS Opioid analgesic
Closed wound drain - ANS Restore suction by compressing the drain after emptying it
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