A child returns from exploratory abdominal surgery following a gunshot wound to the abdomen. Which nursing intervention would the nurse omit from the plan of care for this child?
1. NPO status until bowel sounds return
2. Frequent assessment of the surgical site
3. Avoiding narcotics to prevent depression of the respiratory system
4. Allow parents at the bedside as soon as possible.
3
Rationale 1: This is standard postoperative care.
Rationale 2: The surgical site must be visualized frequently for bleeding.
Rationale 3: Pain management is essential and narcotic medications will be used. The nurse will monitor the respiratory status, but it is inappropriate to withhold pain management.
Rationale 4: This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.
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A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.)
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The family of a neutropenic client reports the client "is not acting right." What action by the nurse is the priority?
a. Ask the client about pain. b. Assess the client for infection. c. Delegate taking a set of vital signs. d. Look at today's laboratory results.
The young woman asks the nurse about breast augmentation surgery. An appropriate response by the nurse would be:
A) "It is a very common surgery and the technique has been perfected." B) "It has been proven that women who have breast augmentation are at greater risk for breast cancer." C) "There is no evidence of implants causing cancer, but the implants do make detection of cancer more difficult." D) "You might want to think about it, because the scar tissue distorts the breasts."
Many patients find it difficult to incorporate an exercise program into their daily lives because of time constraints
For these patients, it is beneficial to reinforce that many ADLs are used to accumulate the recommended 30 minutes or more per day of moderate-intensity physical activity. When instructing these patients, the nurse explains that a. Housework is not considered an aerobic exercise. b. To strengthen back muscles, the patient should bend using back muscles. c. Daily chores should begin with gentle stretches. d. The patient should stick to one chore until it is done before beginning a new one.