A client with a hernia decides to manage the herniation with a truss. The nurse would emphasize which of the following?
A) Using laxatives to ensure regular bowel movement
B) Wearing warm, woolen clothes to avoid dryness
C) Applying a sunscreen to prevent exposure to direct sunlight
D) Using cornstarch to absorb moisture in the area
D
Feedback:
When a client is managing herniation with a truss, the nurse informs the client to keep the skin clean and dry or to use cornstarch to absorb moisture. This minimizes the risk for infection. Use of warm, woolen clothes will not help reduce moisture; it may increase the moisture and increase the risk of infections. If the client's bowel movements are regular, laxatives would not be necessary. However, the client would need teaching to prevent constipation. Applying sunscreen is a general recommendation for any client to reduce the risk of exposure to ultraviolet radiation from the sun.
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A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Applying water-soluble lip balm to the client's lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy
The client's arterial blood gas sample reveals pH 7.32, PaCO2 48 mm Hg, and HCO3– 22. Which does the nurse implement?
1. Instruct client to breathe into a paper bag. 2. Activates the emergency resuscitation team. 3. Instructs the client to cough and deep breathe. 4. Gives the client sodium bicarbonate by mouth.
Which nursing action is correct when performing the straight-leg raising test for an ambulatory patient with back pain?
a. Raise the patient's legs to a 60-degree angle from the bed. b. Place the patient initially in the prone position on the exam table. c. Have the patient dangle both legs over the edge of the exam table. d. Instruct the patient to elevate the legs and tense the abdominal muscles.
The use of weapons of mass destruction or natural disasters such as earthquakes will often have more casualties because:
1. They cause the most widespread destruction. 2. Victims have little time to make evacuation preparations. 3. Those with chronic conditions cannot escape in time. 4. The early warning systems are not effective.