Nursing Actions in Clinical Scenarios

Exc. 3 1.day.A man, 28 years old, diagnosed withindiarrhea, wasarea, admitted to bowel the hospital on the4x/day, 3rd Patients with complaints of pain the infusion watery movements nausea, no appetite. Examination results: the infusionis insertion area looked swollen, reddish, felt warm, the infusion drip was stuck.What the appropriate nursing action in this case? A. Collaborate in administering analgesics B. Apply a warm compress to the painful area C. Remove the IV and replace it with another insertion site D. Give a gentle massage to the swollen area E. Clean around the infusion insertion area with disinfectant Answer Key: C. Remove the IV and replace it with another insertion location Discussion: •phlebitis. Complaints of pain, hands that appear swollen redsetand feelright warm identify theif you riskhave of So removing and replacing the infusion is the action even only used the infusion set for 2 days. •theCollaboration inand giving analgesics, cleaning thetoinfusion witharea disinfectant, massaging swollen area giving warm compresses the painful are not efforts to treat phlebitis. 2.3. The A woman, 48complained years old, diagnosed with type II DM, was admitted to the with hospital on day patient of dizziness and weakness after being injected insulin 3 hours ago. Examination results: patient was restless, cold sweat, pale mucous membranes, fluctuating blood glucose levels, received unitspatient? of insulin injection.Whathistory is theofprimary nursing action that should be given 12 to this A. Check blood sugar levels B. Observe vital signs C. Provide oral sugar intake D. Encourage deep breathing relaxation E. Observe the degree of discomfort Answer Key: A. Checking blood sugar levels Discussion: 1.testGiving 12 units of insulin tosupervision patients with unstable blood glucose levels (fluctuating results), requires close because the patient may experience hyperglycemia or hypoglycemia. Therefore, first step to take if a patient shows the signs and symptoms above is to check bloodthe glucose levels. 2.levels. Providing oral sugar intake is a choice of action taken after first knowing blood glucose 3.problem Observing and degree of discomfort can be done after the patient's main has vital beensigns resolved. 3.with A toddler girl, 2ofyears old, was brought bybreathing. her parentsAssessment to the Community Health Center complaints coughing and difficulty results: symmetrical chest movement, no chest wall retraction, no additional breathto sounds, respiratory frequency 30x/minute, temperature 36.5oC.What data needs be studied further in this case? A. Ratio of inspiration and expiration B. Use of respiratory muscles C. Oxygen saturation D. Tissue perfusion E. Blood pressure Answer Key: C. Oxygen saturation Discussion: Based on MTBS comeassessment: with complaints of coughing and/or difficulty breathing should2019, carrychildren out the who following 1. How long the complaint has been felt. 2. Respiratory frequency in 1 minute. 3. Is there chest wall tension? 4. Is therewheezing. 5. Oxygen saturation value. 4.breath. A boy,Assessment 11 years old,results: was admitted to the warm, children's room with complaints of shortness of acral palpable respiratory rate 20x/min shallow, middiastolic murmur audible, BP 100/60mmHg,data temperature 36.7°C. Mothers say thatcase? children get tired quickly after activities.What needs to be studied further in this A. Oxygen saturation B. Effectiveness of peripheral perfusion C. TTV when changing position D. TTV before and after activity E. Activities carried out while in hospital Answer Key: D. TTV before and after discussion activities: Data on theactivity case suggests heartproblems problems.which Patients with heartbyproblems usually experience intolerance are indicated complaints during activities. So, to strengthen the diagnosis, TTV needs to be studied before and after activities. 5.clinic. A toddler girl, 1.5 yearsassessment, old, was taken by her mother tothe thechild growth and development As a result of the the mother said that had a history of PDA. The nurse will assess the child's growth and development. The nurse explains the procedure the mother, prepares the tools used, and asks the child's date of birth.What is the next to action in this case? A. Ask the child to jump B. Calculate chronological age C. Set a comfortable position D. Ask about the child's development E. Make a straight line on chronological age Answer Key: B. Calculating chronological age Discussion:In the case above, the nurse will assess the child's growth and development. The steps that the nurse has carried out are explaining the procedure to the mother, preparing the tools to be used, and asking for the child's date of birth.Next stageAfter knowing the child's date of birth, you can calculate the child's chronological age. 6.results: A boy,feeling 14 yearsshort old,ofisbreath, admitted to the pediatric ward28x/minute. with a diagnosis ofcarry VSD.out Assessment respiratory frequency Nurses collaborative actionstube to administer oxygen. The nurse her action hands,inprepares tools, connects the oxygen to the oxygen cylinder. Whatwashes is the next this case? A. Check oxygen saturation levels B. Calculate oxygen requirements C. Adjust the oxygen dose D. Put the mask on the client E. Fixing the mask Answer Key: C. Adjusting the oxygen dose Discussion:In the case above, thehas nurse will take collaborative actionpreparing to administer oxygen. The steps that the nurse carried out are washing hands, tools, connecting the oxygen hose to the oxygen cylinder.Next stageis to ensure oxygen is flowing and then adjust the oxygen dose (oxygen requirement). 7.rhonchi A boy,in6 years old,lobe, is admitted tobreathing, the pediatric ward with pneumonia. Assessment results: the right difficulty discharge in the nose. Based on adviseThe doctor planned to administer nebulization. nurseshould in charge prepares equipment and adjusts the patient's position.What nextThe action the nurse takethe in this case? A. Put the medicine into the tube B. Place the oxygen hood C. Turn on the inhalation machine D. Set the time of giving E. Observe inhaled vapors Answer Key: A. Putting the medicine into the tube Discussion:The dataofinnebulization. the case above isnurse that has the nurse tooktheaction based on the doctor's advice in the form The prepared tools and adjusted theturn patient's position.Next stepWhat the nurse does is insert the medicine into the tube, on machine,time. observe the inhalation vapor, place the mask on the patient, andthesetinhalation the administration