🌿 The client's SpO₂ dropped from 97% to 92%, indicating decreased myocardial oxygenation. Oxygen is a priority intervention to meet tissue demands during acute chest pain.

🌿 Chest pain radiating to the arm and worsening from 4/10 to 7/10, alongside shortness of breath and sinus tachycardia, suggest myocardial ischemia.

🌿 Sublingual nitroglycerin promotes vasodilation, decreasing cardiac workload and improving perfusion.

🌿 This sequence supports acute coronary syndrome management by first ensuring oxygenation, then addressing ischemic pain.

🌸 This large-for-gestational-age (LGA) newborn has progressively increasing RR and grunting, which are hallmark signs of transient tachypnea of the newborn (TTN).

🌸 TTN is common in C-section deliveries due to delayed clearance of lung fluid.

🌸 The baby's weight (4200 g) increases risk for neonatal hypoglycemia due to possible hyperinsulinemia from maternal diabetes.

🌸 Monitoring both respiratory status and blood glucose is essential in the immediate neonatal period.

🍃 Dabigatran is sensitive to moisture and must be kept in its original manufacturer’s bottle with the desiccant to maintain potency.

🍃 Transferring it to a pillbox or other container may compromise effectiveness and increase the risk of treatment failure.

🍃 The capsule should never be crushed, as this alters the drug's absorption and increases bleeding risk.

🍃 It also does not require refrigeration and should be kept at room temperature.

A change in behavior post-trauma

🟪 Behavioral changes after trauma, such as withdrawal or emotional numbness, are early signs of psychological distress.

🟪 This finding is particularly significant in adolescents, who may have difficulty verbalizing their emotions.

🟪 These behaviors warrant further assessment for acute stress disorder or post-traumatic stress disorder (PTSD).

Witnessing the death of loved ones

🟪 Exposure to death, especially of close family members, is a severe psychological trauma.

🟪 Witnessing such events increases the client’s risk for PTSD, depression, and survivor’s guilt.

🟪 This level of trauma demands follow-up by a mental health provider to initiate appropriate support.

Experiencing nightmares

🟪 Recurrent nightmares are one of the hallmark signs of PTSD in adolescents and adults.

🟪 These nightmares can disrupt sleep and contribute to emotional instability and fatigue.

🟪 Addressing sleep disturbances early can help reduce long-term psychological impacts.

Using marijuana to cope

🟪 The client’s use of marijuana to “clear their mind” is a form of maladaptive coping.

🟪 Adolescents using substances after trauma are at increased risk for dependence and emotional avoidance.

🟪 This behavior requires mental health evaluation and counseling to promote healthier coping mechanisms.

🌻 Selecting a palpable, straight vein improves insertion accuracy and reduces complications such as infiltration or phlebitis.

🌻 Avoiding veins in flexion areas or curved veins minimizes the risk of vein trauma or catheter dislodgement.

🌻 The nondominant arm is preferred for IV placement to maintain client mobility and comfort.

🌻 The client's arm should be lowered, not elevated, to promote venous filling before cannulation.

Use soap and water to provide perineal care

🟩 Performing perineal care with soap and water helps reduce bacterial colonization near the urinary meatus.

🟩 This basic hygiene measure is essential to minimize the risk of catheter-associated urinary tract infections (CAUTIs).

🟩 It should be done routinely and after episodes of incontinence to maintain cleanliness around the catheter site.

Empty the drainage bag when it is half full

🟩 Emptying the bag at the half-full mark prevents backflow of urine into the bladder, which can carry bacteria.

🟩 Overfilled drainage bags increase the risk of urinary reflux and contamination, both of which can lead to infection.

🟩 This simple action supports effective urinary elimination and infection prevention.

Review the need for the indwelling urinary catheter daily

🟩 Indwelling catheters should be used only when absolutely necessary and discontinued as soon as possible.

🟩 Daily review helps ensure the catheter remains only for valid clinical indications, reducing the duration of exposure.

🟩 This practice is a core principle in preventing CAUTIs and aligns with CDC catheter care guidelines.

Deep Venous Thrombosis:

🟧The client presents with unilateral leg swelling, pain, and warmth, which are classic signs of DVT.

🟧 These symptoms, combined with recent immobility and advanced age, elevate the client’s risk profile significantly.

🟧 DVT must be recognized quickly due to the risk of life-threatening pulmonary embolism if the clot migrates.

Check for pedal pulses and signs of ischemia:

🟧Assessment of peripheral pulses and limb perfusion helps detect compromised circulation, which may suggest thrombus extension or arterial involvement.

🟧 It also aids in distinguishing DVT from conditions like compartment syndrome or arterial occlusion.

🟧 Regular monitoring supports early intervention if ischemia develops, preserving tissue viability.

Request a prescription for a lower-extremity Doppler flow study:

🟧Doppler ultrasound is the diagnostic standard for DVT, allowing visualization of venous blood flow and thrombus identification.

🟧 This test is noninvasive and widely used to confirm suspected cases before initiating anticoagulation.

🟧 Accurate diagnosis ensures appropriate treatment and prevents unnecessary anticoagulant use.

PT/INR and platelet count:

🟧 If anticoagulants like warfarin or heparin are used, these labs are critical for assessing bleeding risk and therapeutic range.

🟧 Platelet monitoring also helps detect heparin-induced thrombocytopenia, a serious adverse effect.

🟧 Frequent lab checks ensure safe dosing and reduce complications.

Signs of bleeding after anticoagulation initiation:

🟧Clients on anticoagulants must be monitored for bruising, hematuria, GI bleeding, or altered mental status.

🟧 These signs can indicate serious internal bleeding and require prompt dose adjustments or reversal agents.

🟧 Monitoring ensures treatment does not shift from clot prevention to bleeding-related harm.

🌿 The inactivated influenza vaccine is safe during all trimesters and recommended to protect both the mother and fetus from complications.

🌿 Pregnant individuals are at higher risk for flu-related complications, and vaccination provides passive immunity to the newborn.

🌿 Other options are incorrect because rubella and varicella are live vaccines (contraindicated in pregnancy), and hepatitis B is safe if needed.

🌿 Teaching should focus on distinguishing safe vaccines during pregnancy and which ones should wait until postpartum.

🌸 Medicaid provides financial coverage for prenatal, delivery, and postpartum care, making it the most appropriate action for a pregnant adolescent with economic concerns.

🌸 The adolescent has not expressed mental health distress or a desire for adoption, so referral to mental health or adoption services is premature.

🌸 While family support is valuable, the nurse must first empower the adolescent with resources, especially in confidential or independent cases.

🌸 This action promotes access to essential maternal and fetal health services early in the pregnancy.