The nurse is performing passive range of motion on the client and notes that the client's ankle is red, edematous, and painful to the touch. Which action by the nurse is the most appropriate?
1. Perform range of motion very gently to the ankle.
2. Perform normal range of motion to the ankle.
3. Skip range of motion in this joint and move on to the next joints.
4. Notify the health care provider before performing range of motion to this joint.
4
Rationale 1: If a joint is traumatized, it is best to avoid ROM exercises until consulting with the primary care provider.
Rationale 2: After speaking with the health care provider, if ROM is indicated, the nurse would not move the joint to the point of resistance or pain, and might consult with a physical therapist.
Rationale 3: The traumatized joint should not just be skipped, as it should be brought to the attention of the health care provider so diagnostic tests can be performed as indicated.
Rationale 4: If a joint is traumatized, it is best to avoid ROM exercises until consulting with the primary care provider.
Global Rationale: If a joint is traumatized, it is best to avoid ROM exercises until consulting with the primary care provider. After speaking with the health care provider, if ROM is indicated, the nurse would not move the joint to the point of resistance or pain, and might consult with a physical therapist. The traumatized joint should not just be skipped, as it should be brought to the attention of the health care provider so diagnostic tests can be performed as indicated.
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The nurse reassesses the patient who has been in shock to evaluate the nursing interventions used. The criterion that documents successful interventions is which of the following?
1. The patient's pulse strength against the nurse's fingertips is of increasing strength; there is an increasing blood pressure and increased alertness. 2. The patient's pulse strength against the nurse's fingertips is of decreasing strength; there is a decreasing blood pressure and increased alertness. 3. The patient's pulse strength against the nurse's fingertips is of increasing strength; there is decreasing blood pressure and decreased alertness. 4. The patient's pulse strength against the nurse's fingertips is the same as the last reading; there is no increase in blood pressure or alertness.
The initial focus of the nursing management of clients who are in shock is to:
a. identify the type of shock b. initiate appropriate interventions quickly c. discuss client status with the family d. administer medications as ordered
How do the economics of the health care system define access to health care in the United States?
A) Health care is a right of all individuals. B) Health care is a privilege, not a right, of all individuals. C) Health care is a right of individuals covered by specified programs such as Medicare. D) Health care is a right of individuals covered by privately financed insurance.
Infection control relies on the individual health care worker
True False