A new nurse is caring for a child after spinal fusion to correct scoliosis. Which action by the new nurse causes the experienced nurse to intervene?
A.
Assesses neurological status and vital signs every hour
B.
Instructs patient to turn by pulling on side rails
C.
Monitors chest tube for air leakage and drainage
D.
Promotes use of the incentive spirometer each hour
ANS: B
After spinal fusion, the patient must be logrolled to turn. Logrolling involves two nurses turning the patient as one single unit so that the spine is maintained in a straight line. The other actions are appropriate.
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An example of a breach of a client's constitutional right to privacy occurs when the nurse
a. discusses the client's history with other staff during care planning. b. releases information to the client's employer without consent. c. documents the client's daily behaviors during hospitalization. d. asks the client's family to share information about prehospitalization behavior.
A nurse administering collagenase (Santyl) topically to a client must be certain not to use which of the following products that can inactivate the enzymes in collagenase (Santyl)? Select all that apply
A) Detergents B) Water C) Iodine D) Silver E) Mercury
During a home visit the nurse notes that the caregiver does not apply clean gloves before removing the patient's leg wound dressings. What should the nurse do to encourage infection control practices in this home?
1. Place the box of gloves next to the sink in the bathroom. 2. Remind the caregiver to wash hands after completing wound care. 3. Place the box of gloves next to the bag used to discard soiled dressings. 4. Encourage the caregiver to touch only the edges of the soiled dressings.
The conjuctiva in a healthy patient is usually white
A) True B) False