The nurse is caring for a child who is terminally ill. The nurse knows the major goals of caring for a dying child are: (Select all that apply.)
1. Promote comfort.
2. Keep the child pain free.
3. Keep the airway free of secretions.
4. Position change.
5. Encourage favorite food.
1.
1, 2, 3, 4, 5
Rationale:
1. A major goal in care of the dying child is to promote comfort.
2. Provide analgesia to promote optimal pain relief. Oral, transdermal, or rectal analgesia is available for families who choose to withhold intravenous fluids.
3. Physiologic care includes keeping the airway clear of secretions.
4. Changing position frequently prevents skin breakdown
5. Offering and encouraging favorite foods and liquids as tolerated should be part of the physical care.
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The nurse enters the client's room and finds the client sitting on the floor beside the bed. The nurse asks the client if he fell, and the client denies a fall. Which of the following actions should the nurse take?
1. Leave the client on the floor and get another nurse to witness the event. 2. Assess the client and complete an incident report. 3. Document in the chart that the client fell out of bed. 4. Accept the client's statement that she did not fall.
Administer 50 mL of an antibiotic in 25 minutes. The administration set delivers 10 gtt/mL. _____
a. 20 gtt/min b. 40 gtt/min c. 50 gtt/min d. 100 gtt/min
Which of the following provides the best explanation for the importance of the "Go Red" and "The Heart Truth" campaigns?
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A patient with active tuberculosis who has been taking isoniazid (INH, Nydrazid) and rifampin (RIF, Rifadin) reports having urine that is an orange color. What is the nurse's best action?
a. Obtain a specimen for culture and test the urine for occult blood. b. Reassure the patient that this is a normal drug side effect. c. Hold the dose and contact the prescriber. d. Document the report as the only action.