The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which of the following actions helps to minimize skin breakdown?
a. Encouraging the patient to bathe before surgery
b. Securing attachments to the operating table with foam padding
c. Periodically adjusting the patient during the surgical procedure
d. Measuring the time a patient is in one position during surgery
B
Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with monitoring the situation but does not prevent skin breakdown.
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A nurse is preparing a teaching plan and is determining the best time for teaching. Which of the following would be an inappropriate time for client teaching? Select all that apply
A) When there are visitors B) Immediately prior to discharge C) The day of admission D) While the client is sedated E) While the client is in pain
A patient has arrived at the intensive care unit with a head injury. On admission, the patient is talking and is a little drowsy, but oriented
Two hours later, the nurse discovers that the patient is talking at a rapid pace and keeps repeating his words. Which of the following examples best de-picts Benner's stages and appropriate critical thinking processes in this situation? a. Advanced beginner—thinks that the patient is trying to be funny. b. Competent—thinks that the patient is experiencing effects from cerebral edema. c. Novice—thinks that the patient is stressed and has had a surge of adrenalin. d. Proficient—thinks that the patient is waking up from a coma.
Which action would the nurse include in a primary prevention program in the community to help reduce the incidence of HIV infection?
A) Provide treatment for clients who test positive for HIV B) Monitor viral load counts periodically C) Educate clients about how to practice safe sex D) Offer testing for clients who practice unsafe sex
Discharge planning for the patient admitted to the acute care facility ideally begins
a. shortly after the patient is admitted to the acute care setting b. the morning of discharge c. at the time of the first post-discharge visit to the primary care provider d. only when the patient states she is ready to listen to the process