Inadequate ventilation and perfusion, increase in pH, and cell hypoxia

Inadequate perfusion and lactic acid accumulation, and metabolic alkalosis

Inadequate perfusion, lactic acid accumulation, and dysfunction of potassium pump

Inadequate perfusion, release of digestive enzymes, and cell hypoxia

Maintain a sodium nitroprusside infusion to control the client's hypertension

Provide support and comfort to the client until they are transferred to the surgical suite

Monitor the client for pain and provide analgesia as ordered

Ensure the client's family members are aware of the severity of the situation

A well-lit room with two side rails up

A well-lit room with four side rails up

A dim-lit room with four side rails up

Clamp the chest tube

Notify the healthcare provider (HCP)

Replace the chest tube drainage system

0900: The client states, “I have not received this type of testing before, what is it

about?” Pt was provided with education about sickle-cell anemia. M.H., RN

1000: Late entry for [0830 hrs.], the client was assessed BP 90/62, temp 97.5

°F (36.4 °C), HR 77 bpm, RR 14.

M.H., RN

0930: 2 vials of blood were obtained for sickle cell test to be performed. The client reported no pain during the procedure. M.H., RN

1030: The client’s vitals are stable but the client is apparently experiencing pain during testing. M.H., RN

Apply acetic acid and hydrocortisone drops

Pull on the pinna and gently irrigate the area

Administer antivirals

Hypocalcemia indicated by Chvostek's sign

Hypercalcemia indicated by Trousseau's sign

Hypocalcemia indicated by Trousseau's sign

Hypercalcemia indicated by Chvostek's sign

The client leaves a small piece of toilet paper in the collection container

The client states they had a bowel movement after collecting the urine sample

The client rinses with sterile water after using the chlorhexidine swabs to cleans the perineum

The client has a drop of urine on the outside of the collection container