Assignment Task:
Nurses' Notes 0600: Adventitious lung sounds auscultated in lower lobes bilaterally. Incentive spirometry encouraged. Face and neck warm to touch. Client reports headache. Abdomen distended. Last bowel movement 2 days ago with hard stool. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take 1 Action to Take 2 Condition Most Likely Experiencing Parameter to Monitor 1 Parameter to Monitor 2 Actions to Take Perform suctioning. Place client in supine position. Prepare to administer nifedipine. Prepare to administer atropine sulfate. Assess for urinary retention. Condition Most Likely Experiencing Autonomic dysreflexia Arteriovenous malformation Dysrhythmia Atelectasis Parameters to Monitor Electrocardiogram (ECG) Lung sounds Deep tendon reflexes Changes in vision Blood pressure