Page 230 - Saunders Comprehensive Review For NCLEX-RN

The Pyramid to Success also focuses on the assessment techniques for a health and
physical assessment of the adult client and collecting both subjective and objective
data. Perioperative nursing care and monitoring for postoperative complications is
also a priority. Client safety related to positioning and ambulation are important
concepts addressed on the NCLEX. Because many surgical procedures are
performed through ambulatory care units (1-day-stay units), Pyramid Points also
focus on preparing the client for discharge, assisting with teaching related to the
prescribed treatments and medications, follow-up care, and the mobilization of
home care support services.

Client Needs: Learning Objectives

Safe and Effective Care Environment

Acting as an advocate regarding the client’s wishes
Applying principles of infection control
Collaborating with interprofessional teams
Ensuring environmental, personal, and home safety
Ensuring that the client’s rights, including informed consent, are upheld
Establishing priorities of client assessment and interventions
Following advance directives regarding the client’s documented requests
Following guidelines regarding the use of safety devices
Handling hazardous and infectious materials safely to prevent injury to health
care personnel and others
Identifying the client with at least two identifiers (e.g., name and identification
number)
Informing the client of the surgical process and ensuring that informed consent
for a surgical procedure and other procedures has been obtained
Knowing the emergency response plan and actions to take for exposure to
biological and chemical warfare agents
Maintaining confidentiality
Maintaining continuity of care and initiating referrals to home care and other
support services
Maintaining asepsis and preventing infection in the client when samples for
laboratory studies are obtained
Maintaining precautions to prevent errors, accidents, and injury
Positioning the client appropriately and safely
Preparing and administering medications, using the rights of medication
administration
Preventing accidents and ensuring safety of the client when a fluid or electrolyte
imbalance exists, particularly when changes in cardiovascular, respiratory,
gastrointestinal, neuromuscular, renal, or central nervous systems occur, or
when the client is at risk for complications such as seizures, respiratory
depression, or dysrhythmias
Preventing a surgical infection
Protecting the medicated client from injury

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