The nurse is taking care of a client who is at high risk for skin breakdown. What is the best pressure-reducing device that should be included in the nursing care plan?
A) Use of logroll turns
B) Elevate heels off bed
C) Elevate head of bed no more than 30 degrees
D) Use of trapeze over bed
D
Feedback:
The use of a trapeze over the bed is an example of a pressure-reducing device. Pressure-reducing techniques include use of logroll turns, elevation of heels off bed, and elevation of head of bed no more than 30 degrees.
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A 6-year-old is admitted to the emergency department after being rescued from a pond. The child fell through the ice while ice skating. What can a nurse expect when rewarming a hypothermic patient?
A) To assess oral temperature frequently B) To provide continuous ECG monitoring C) To administer unwarmed oxygen D) To find a strong pulse
An out-of-state caller becomes irate when the nurse cannot provide information over the telephone about a hospitalized friend. The caller says, "If you know what is good for you, you had better tell me." Has a civil assault occurred?
1. Yes, there is an indication that the caller has the physical strength to do harm. 2. Yes, the threat of harm is assault. 3. No, actual physical contact must be made for it to be assault. 4. No, the caller is out of state and cannot reach the nurse.
A woman in her 30th week has a cervical length estimated at 1 cm. Should you be concerned?
A) Yes; she may be at risk for preterm labor. B) Yes; she most likely has a bicornuate uterus. C) No; this is a normal measurement for this gestational age. D) Yes; it likely indicates the fetus is in the breech position.
Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?
a. Right atrium, right ventricle, left ventricle, left atrium b. Right atrium, left atrium, right ventricle, left ventricle c. Right atrium, right ventricle, left atrium, left ventricle d. Right atrium, left atrium, left ventricle, right ventricle