The critical-care nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. In planning the patient's care, which measure will the nurse implement to decrease the patient's risk of developing pulmonary emboli (PE)?
A) Early ambulation
B) Increased dietary intake of protein
C) Maintaining the patient in a supine position
D) Administering aspirin with warfarin
Ans: A
Feedback: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stocking are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin as it will increase the patient's risk for bleeding.
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The nurse is assessing a child previously diagnosed with fetal alcohol syndrome. Which of the following statements by the client's adoptive mother are consistent with the child's diagnosis? Standard Text: Select all that apply
1. "It seems as if one of his eyelids is droopy.". 2. "There's a firm little bump on his eyelid but he says it doesn't hurt.". 3. "His eyes almost look cloudy.". 4. "He has required glasses to see well since he was 2 years old.". 5. "His eyelids look they have turned under and he complains that his eyes hurt.".
The nurse would explain to a client that an "allergy" differs from an "irritation" in that an allergy
a. affects the skin and mucous membranes only. b. is an immune response. c. is inconsistent. d. can be totally desensitized.
The nurse assisting with the oculovestibular response (OVR) test on a client recognizes that the brain stem is intact when the client's eyes
a. demonstrate sustained nystagmus. b. do not deviate with the instillation of ice water. c. rapidly move toward the ear irrigated with warm water. d. slowly move toward the ear irrigated with ice water.
The caring-civility link is best exemplified by which of the following?
a. Helping in disasters in foreign countries b. Conducting scholarly research into over-coming health-care disparities c. Accepting criticisms from physicians even though unjustified d. Making nursing assignments based on clients' needs and nurses' skills