The nurse is planning to perform postural drainage on a patient who is receiving continuous tube feedings. What should the nurse do before performing the treatment? (Select all that apply.)
a. Stop the tube feedings for 1 to 2 hours before and after postural drainage.
b. Check for residual feeding in the patient's stomach and hold treatment if greater than 100 mL.
c. Give the prescribed inhaled bronchodilator 20 minutes before the procedure.
d. Auscultate all lung fields, assess vital signs, and draw arterial blood gas levels (ABG).
B, C
Stop all continuous gastric tube feedings for 30 to 45 minutes before postural drainage. Check for residual feeding in the patient's stomach; if greater than 100 mL, hold treatment. If the patient is receiving inhaled bronchodilator, nebulizer, or aerosol treatment, postural drainage is performed 20 minutes after such therapy is provided. Assessing lung sounds and vital signs, but not blood gas levels, is routinely done. Instead, pulse oximetry readings can be assessed.
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The legal aspects of documentation require which of the following?
a. factual and time-sequenced descriptive entries b. legible printing c. proof or evidence of any form of malpractice or negligence that occurs during a client's stay d. lack of abbreviations
The nurse is caring for a patient with acute pericarditis. What nursing management would be instituted to minimize complications?
A) The nurse keeps the patient isolated to prevent nosocomial infections. B) The nurse encourages coughing and deep breathing. C) The nurse helps the patient with activity restrictions until the pain and fever subside. D) The nurse encourages increased fluid intake until dehydration is resolved.
The nurse recognizes that the patient who is being evaluated for a visual impairment does not have glaucoma because the tonometry reveals an intraocular pressure of:
1. 18 mm Hg. 2. 28 mm Hg. 3. 45 mm Hg. 4. 52 mm Hg.
A schizophrenic client says, "I'm away for the day ... but don't think we should play or do we have feet of clay?" Which alteration in the client's speech does the nurse document?
A. Neologism B. Word salad C. Clang association D. Associative looseness