The nurse is caring for an alert client who has been in bed for three days. When performing a focused assessment, the nurse checks the skin of the legs and feet for which of the following?
1. Dependent edema
2. Foot drop
3. Varicose veins
4. Cyanosis
1
Rationale: The feet and legs should be checked for dependent edema, which can increase the risk for skin breakdown. Foot drop is more likely to occur in the client with reduced level of consciousness, who is not moving the foot. Varicose veins and cyanosis would not be an anticipated risk of immobility unless other problems exist.
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A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)
a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication
The nurse is explaining the importance of measuring intake and output to the client and his family. Intake that must be measured includes:
1. Urine 2. Stool 3. GI suction 4. Ice chips 5. Wound drainage
Which action by a nurse shows positive regard?
a. Making rounds according to the daily assignment. b. Administering daily medication as prescribed. c. Examining own feelings about a patient. d. Staying with a patient who is crying.
The mother of a child with ESRD asks the nurse why her son is getting an injection of erythropoietin. When responding to the mother, the nurse incorporates understanding of which of the following as the rationale?
A) To treat low calcium levels B) To stimulate growth in stature C) To stimulate red blood cell growth D) To correct acidosis