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Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

The nurse is caring for a postoperative patient who just came out of recovery from having their appendix removed (appendectomy). The nurse works at a small, community hospital and is aware that an IV pump may or may not be available, depending on how many IV pumps are in use each day. The provider orders 1,000 mL of normal saline over eight hours. The drop factor for the IV tubing is 15 gtt/mL.
1 .
Is normal saline categorized as an isotonic, hypotonic, or hypertonic solution?
2 .
If the fluid is infused by pump, what rate should be programmed into the pump?
3 .
If the fluid is infused by gravity, how many drops should fall into the drip chamber each minute?
Mr. Ramirez is a 72-year-old male admitted with serious burns obtained from a motor vehicle accident. Upon rounds, the provider orders plasma to be administered.
4 .
What must the nurse do to prepare for the plasma transfusion?
5 .
Mr. Ramirez asks, “What is plasma?” How should the nurse respond?
6 .
Upon picking the plasma up from the blood bank, the nurse notices it is yellow. What should the nurse do?
During the administration of the plasma, Mr. Ramirez begins coughing and appears to be having difficulty breathing. Vital signs are taken. Blood pressure is 150/93; heart rate is 104; temperature is 98.3°F (36.8°C); respirations are 26; and oxygen saturation is 93 percent. Baseline vital signs were blood pressure, 118/75; heart rate, 86; temperature, 98.2°F (36.8°C); respirations, 18; and oxygen saturation, 94 percent.
7 .
Which of the assessment findings are concerning?
8 .
What other assessments should the nurse perform?
9 .
What other symptoms is the nurse looking for in their assessments?
10 .
What is going on with Mr. Ramirez?
11 .
What actions should the nurse take?

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