Page 1749 - Saunders Comprehensive Review For NCLEX-RN

▪ Assist the client to identify ways to reduce stress.

▪ Teach relaxation techniques.
▪ Instruct the client in how to incorporate relaxation techniques into the daily
living pattern.

▪ Instruct the client and family in the technique for monitoring blood pressure
(BP).
▪ Instruct the client to maintain a diary of BP readings.

▪ Emphasize the importance of lifelong medication.
▪ Instruct the client and family about dietary restrictions, which may include
sodium, fat, calories, and cholesterol.

▪ Instruct the client in how to shop for and prepare low-sodium meals.
▪ Provide a list of products that contain sodium.
▪ Instruct the client to read labels of products to determine sodium content,
focusing on substances listed as sodium, NaCl, or MSG (monosodium
glutamate).
▪ Instruct the client to bake, roast, or boil foods; avoid salt in preparation of foods;
and avoid using salt at the table.
▪ Instruct the client that fresh foods are best to consume, and to avoid canned
foods.
▪ Instruct the client about the actions, side effects, and scheduling of medications.
▪ Advise the client that if uncomfortable side effects occur, to contact the primary
health care provider or cardiologist and not to stop the medication.
▪ Instruct the client to avoid over-the-counter medications.
▪ Stress the importance of follow-up care.

Priority Nursing Actions

Pulmonary Edema

1. Place the client in a high-Fowler’s position.
2. Administer oxygen.
3. Assess the client quickly, including assessing lung sounds.
4. Ensure that an intravenous (IV) access device is in place.
5. Prepare for the administration of a diuretic and morphine sulfate.
6. Insert a Foley catheter as prescribed.
7. Prepare for intubation and ventilator support, if required.
8. Document the event, actions taken, and the client’s response.

Practice Questions

600. A client is admitted to the emergency department with chest pain that is
consistent with myocardial infarction based on elevated troponin levels.

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