Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction syndrome (MODS) in a critically ill patient who is being mechanically ventilated?
1. Enforcing hand washing before and after touching a patient
2. Following an evidence-based ventilator bundle
3. Using urinary catheters to prevent perineal skin breakdown
4. Complying with turning and repositioning schedules
5. Restricting visitors to immediate family only
1, 2, 4
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The nurse plans care for a client with impaired swallowing. Which outcome does the nurse include in the client's plan of care?
1. Pouches food boluses in the mouth. 2. Observes upward movement of larynx. 3. Stabilizes weight for 3 consecutive days. 4. Swallows four times after each mouthful.
Which pressure ulcer presents as a full-thickness loss with extensive involvement of supporting structures?
1) Stage I 2) Stage II 3) Stage III 4) Stage IV
MC During a home visit, the nurse should
A. Continue to validate the accuracy of the assessment and resulting diagnosis. B. Focus on the plan of care as it is written. C. Concentrate on the already-identified needs. D. Plan to write an evaluation.
Which actions would you perform to safely administer Y.W.'s medications through the PEG
tube? Select all that apply. a. Position Y.W. in a side-lying position with the head of bed flat. b. Temporarily stop the feeding while administering the medications. c. Flush the PEG tube with water after medication administration. d. Hold the tube feeding for 2 hours after administering the medication. e. Place the medications into the feeding bag with his tube feed formula. f. Aspirate for gastric residual before administering the medications.