The nurse prioritizes which intervention in a client with xerostomia secondary to radiation therapy to the neck area?
a. Applying lotions and oils to affected areas
b. Wearing a hat to decrease heat loss
c. Providing oral care after meals and at bedtime
d. Monitoring vital signs every 4 hours
C
Head and neck radiation may damage the salivary glands, may cause dry mouth (xerostomia), and may increase the client's lifelong risk for tooth decay. Instruct clients to avoid using lotions or ointments in these areas unless the radiologist prescribes them. Xerostomia is not associated with hair loss, which might require a hat. Monitoring vital signs is important for any client re-ceiving radiation therapy but is not a priority for the client with xerostomia.
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Which of the following actions would the nurse prioritize for the patient who is experiencing chronic back pain that interferes with activities of daily living (ADLs)?
a. Maintain a pain journal to document quality of his pain experience. b. Meet with the healthcare team to discuss a pain management plan. c. Attempt to take only analgesic medication when absolutely needed. d. Suggest use of a deep-pressure back massage with effleurage technique.
A nurse is assessing a newborn who has been classified as small for gestational age. Which of the following would the nurse expect to find? (Select all that apply.)
A) Wasted extremity appearance B) Increased amount of breast tissue C) Sunken abdomen D) Adequate muscle tone over buttocks E) Narrow skull sutures
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1. Provider performance 2. Length of stay management 3. Capitation 4. Formularies
While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following?
A) Pericardial friction rub B) Midsystolic click C) Summation gallop D) Aortic ejection click