The nurse considers the client who has an abdominal binder over retention sutures. Which does the nurse instruct the nursing assistant to report as an unexpected outcome?
1. Skin around the binder is dry without redness or edema.
2. The binder hampers the client activity level and mobility.
3. The client's pain level increases to more than 5 out of 10.
4. Respiratory rate is decreasing from 17 breaths per minute.
2
2. The nurse uses a binder over a dressing to secure it in place, facilitate client activ-ity, and protect the skin. The nurse instructs the nursing assistant to observe the client's activity level and mobility with the binder in place because the assistant is trained to perform this task; the assistant is able to determine whether the client is able to change positions, perform range of motion, and ambulate.
1. Assessing the skin around the binder and evaluating trends in data are nursing tasks requiring nursing assessment skills and nursing judgment and evaluation; thus, the nurse avoids delegating skin assessments and data analysis.
3. Determining the client's pain level is a nursing function requiring assessment skills.
4. The nurse expects the nursing assistant to report the respiratory rate and the nurse draws conclusions about the assessment data
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After a methamphetamine overdose, priority nursing and medical measures will center around
a. repeated lavage. b. acidification of urine. c. maintenance of nutrition and elimination. d. reduction of fever and prevention of seizures.
The nurse realizes that which client is at risk for difficulty in urinary elimination?
1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure
The nurse is conducting a group education session for patients who have been diagnosed with depression. The nurse evaluates the education as effective when a patient makes which comment(s) about the cause of depression?
1. "Depression has many causes; they could include environmental as well as brain-based disorders." 2. "Depression includes impaired relationships, and is also an inherited illness." 3. "We really don't know what causes depression; it has not been studied very much." 4. "Depression results from unresolved conflicts in your childhood." 5. "Depression results from parents who are cold and distant and don't really care about their children."
Oxygenated blood flows through which vessel?
a. Superior vena cava b. Pulmonary veins c. Pulmonary artery d. Coronary veins