Answer: Remind the client to change the position often.
( Being for the bed rest for a long time, it is necessary to change position as it can cause pressure ulcer. This is causes when there is pressure occurs to a particular area due to friction of the support or the weight causes decrease in the blood flow to that particular area.
tion: 19-19 of 70 Page: 19 of 70 19 A nurse is assessing a client who...
A nurse is caring for a client who has diarrhea and is receiving intermittent enteral feedings. Which of the following actions should the nurse take? Discard the open can of formula after 36 hr. Administer feeding at a slower rate. Flush the tube with 10 mL of water after feedings. Provide chilled formula. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? Withhold...
a nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 he which of the following actions should the nurse take first
A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? Place the end of the NG tube in water to observe for bubbling. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. Assess the client for a gag reflex. Measure the pH of the gastric aspirate A nurse is caring for a client who...
A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take? o o o o Change the client's position every 4 hr Use friction when cleansing the client's skin Applý a petroleum- based ointment: to the red area Assess the red area for branching
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first? Auscultate bowel sounds. Palpate the abdomen offer pain medication. Administer an antiemetic.
6. A nurse in emergency department is assessing a client in his right lower quadrant who report nausea and vomiting for the first 48 hours, which of the following actions should the nurse take? Palpate the abdomen. Offer medication Administer antibiotic Auscultate bowel sound.
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority? Musculoskeletal weakness Loss of appetite Increase heart rate during physical activity Left lower extremity tenderness A nurse is assessing a client’s ability to balance. Which of the following actions is appropriate when the nurse conducts a Romberg test? Ask the client to extend her arms in front of her body. Ask the client...
42. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign? A. After stroking the lateral area of his foot, the client’s toes contract and draw together. B. After hip flexion, the client is unable to extend his leg completely without pain. C. The client’s voluntary movement is not coordinated. D. The client reports pain and stiffness when flexing his neck.
27. A nurse is caring for a client who has acute heart failure and is receiving furosemide via IV bolus. The nurse should identify that which of the following findings indicates a desired therapeutic effect? Increased sputum production Decreased weight Decreased blood glucose level Increased blood pressure 54. A nurse is assessing a client who receives monthly injections of cyanocobalamin. Which of the following findings indicates a therapeutic effect of the medication? Absence of hand tremors Hematocrit 45% Potassium 3.8...
A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Exhibit) Encourage the client to verbalize feelings. Implement seizure precaution for the client. Administer ondansetron to the client for nausea. Obtain the client’s weight. A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? A client...