[Answer] During the course of a busy shift a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid the physician removes the drain. When the nurse arrives for work the next morning she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take?

Answer: Notify the physician of the documentation omission.

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During the course of a busy shift a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid the physician removes the drain. When the nurse arrives for work the next morning she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take? An expected client outcome is The client will remain free of infection by discharge. When evaluating the client's progress the nurse notes the client's vital signs are within normal limits the white blood cell count is 12 000 and the client's abdominal wound has a … The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40/min arterial BP 98/48 oxygen saturation 82% cardiac monitor showing sinus tachycardia at 138 bpm. What action should the nurse take … During an assessment of a newly admitted client the nurse notes that the client's heart rate is 110 beats/minute his blood pressure shows orthostatic changes when he stands up and his tongue has a sticky paste-like coating. The client's spouse tells the nurse that he seems a little ...

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