Hematocrit

💠 Hematocrit measures the percentage of red blood cells in plasma, making it directly influenced by changes in fluid volume.

💠 In fluid volume deficit, plasma decreases, causing hemoconcentration and an elevated hematocrit.

💠 In fluid volume excess, plasma increases, leading to hemodilution and a decreased hematocrit.

💠 It is one of the most sensitive indicators of intravascular fluid shifts.

💠 Significant dehydration or overhydration will alter hematocrit values.

Urine specific gravity

💠 Urine specific gravity reflects urine concentration, which changes according to hydration status.

💠 In dehydration, urine becomes concentrated, resulting in an increased specific gravity.

💠 In fluid overload, urine becomes dilute, resulting in a decreased specific gravity.

💠 It provides important information about renal response and ADH activity.

💠 It is a primary laboratory indicator used to assess fluid balance.

Sodium

💠 Sodium is the major extracellular electrolyte responsible for regulating water balance.

💠 Changes in fluid volume often result in hyponatremia or hypernatremia.

💠 Sodium concentration determines serum osmolarity and fluid distribution between compartments.

💠 Fluid imbalances frequently alter sodium levels before other electrolytes.

💠 It is a key laboratory value in evaluating hydration and fluid status.

White blood cells

💠 WBC count is primarily affected by infection, inflammation, or immune response, not directly by fluid imbalance.

💠 Although severe dehydration may slightly concentrate blood components, WBC changes are not primary indicators of hydration status.

Magnesium

💠 Magnesium levels are more commonly influenced by renal function, gastrointestinal losses, or medication effects.

💠 It is not typically the first electrolyte altered solely due to changes in body water balance.

💠 Desired dose (D) = 325 mg

💠 Available dose (H) = 650 mg per 5 mL

💠 Use the formula: (D ÷ H) × Volume (V)

💠 (325 mg ÷ 650 mg) × 5 mL

💠 0.5 × 5 mL = 2.5 mL

💠 Nonmaleficence means “do no harm”, requiring healthcare providers to minimize risk and prevent unnecessary injury.

💠 A bone marrow biopsy is an invasive procedure, so the provider must ensure the benefits outweigh the potential risks.

💠 The nurse plays a role in reducing harm by maintaining sterile technique and monitoring for complications such as bleeding or infection.

💠 Pain management and proper aftercare further support the principle of preventing harm.

💠 Performing the biopsy only when medically indicated reflects the ethical obligation to avoid unnecessary harm.

Autonomy

💠 Autonomy refers to the client’s right to make informed decisions, including consenting to the biopsy.

💠 While consent is important, the ethical focus of performing an invasive procedure safely relates more directly to preventing harm.

Fidelity

💠 Fidelity involves keeping promises and maintaining trust in the nurse-client relationship.

💠 It does not specifically address minimizing physical harm from a medical procedure.

Justice

💠 Justice concerns fair and equal treatment in healthcare delivery.

💠 It is not specifically related to the safety considerations involved in performing a biopsy.

💠 The nurse must communicate significant changes in the plan of care to the healthcare provider, especially when a family member declines a recommended service such as home health for PICC management.

💠 A PICC line requires skilled monitoring and sterile technique, and refusal of support can increase the risk of infection or complications.

💠 The provider needs to evaluate whether discharge is safe without home health services and determine alternative plans.

💠 This action supports interdisciplinary collaboration and patient safety.

💠 The nurse does not have independent authority to override, cancel, or enforce discharge plans without provider involvement.

Prohibit discharge without accepting home health nurse referral

💠 The nurse does not have the authority to independently prohibit discharge unless there is an immediate safety concern requiring escalation.

💠 Discharge decisions must involve the provider and the healthcare team.

Explain the need for a trained person to monitor PICC care

💠 Education is important, but simply explaining is not sufficient if the family continues to refuse services.

💠 The provider must be notified to reassess the discharge plan.

Respect the daughter's wishes and cancel the referral

💠 Automatically canceling the referral could place the client at risk for PICC-related complications.

💠 Safety concerns must be addressed through the provider before altering the care plan.

Assessment

💠 Assessment is the first step of the nursing process and involves systematic collection of subjective and objective data.

💠 It includes gathering information through observation, physical examination, health history, and review of records.

💠 Accurate assessment provides the foundation for identifying nursing problems.

💠 Without proper data collection, appropriate nursing diagnoses cannot be made.

💠 All subsequent steps of the nursing process depend on a thorough assessment.

Intervention

💠 Intervention refers to implementing the planned nursing actions to address identified problems.

💠 It occurs after assessment, diagnosis, and planning.

Diagnosis

💠 Diagnosis involves analyzing assessment data to identify actual or potential health problems.

💠 It does not involve collecting new data.

Evaluation

💠 Evaluation determines whether the goals and outcomes have been met after interventions are implemented.

💠 It occurs at the end of the nursing process cycle.

💠 Stopping the transfusion immediately is the priority action when a transfusion reaction is suspected because continued infusion can worsen hemolysis and lead to shock.

💠 Acute reactions such as hemolytic reaction, febrile reaction, or anaphylaxis can rapidly progress and become life-threatening.

💠 The nurse should maintain IV access with normal saline using new tubing after stopping the blood product.

💠 Prompt notification of the healthcare provider ensures rapid medical intervention and appropriate treatment.

💠 Early action prevents complications such as acute kidney injury, disseminated intravascular coagulation (DIC), and hypotension.

Recheck blood type against donor blood

💠 Rechecking compatibility is important but is done after the transfusion is stopped.

💠 Continuing the transfusion while verifying blood type would place the client at further risk.

Notify the blood bank

💠 The blood bank must be notified, but only after the transfusion has been discontinued and the client stabilized.

💠 Patient safety takes priority over administrative reporting.

Assess temperature and blood in urine

💠 Assessment findings such as fever or hemoglobinuria help confirm a reaction.

💠 However, stopping the transfusion must occur before additional assessments to prevent further harm.

💠 Confusion significantly increases fall risk because it impairs judgment, orientation, and awareness of surroundings.

💠 A confused client may attempt to get out of bed without assistance, increasing the likelihood of injury.

💠 Altered cognition affects balance, coordination, and safety awareness.

💠 Falls are a major cause of morbidity in hospitalized clients, especially those with mental status changes.

💠 Nursing priorities include fall precautions, close monitoring, and environmental safety measures.

Stroke — Vomiting

💠 Vomiting alone does not directly place the client at high risk for stroke.

💠 Stroke risk is more closely related to hypertension, atrial fibrillation, or clotting disorders.

Fluid overload — Diarrhea

💠 Diarrhea typically leads to fluid volume deficit, not overload.

💠 Fluid overload is associated with conditions such as heart failure or excessive IV fluid administration.