When assessing the client with a noncontinent urinary diversion, the nurse finds the peristomal skin to be reddened. The nurse should first:
A. Culture any drainage
B. Apply an antiseptic cream to the area
C. Make sure that the area remains dry
D. Change the equipment being used for pouching
C
C. Keep peristomal skin dry. Determine if client has an allergy to barrier and adhesive or an infection.
A. If there is no urinary output for several hours or output is less than 30 ml/hr, and if urine has foul odor, obtain urine specimen for culture and sensitivity to test for possible infection.
B. Assess for presence of yeast infection around stoma, which causes itching, burning; appears as reddened area with maculopapular rash. Notify physician. Apply medicated cream if ordered.
D. Determine if client has an allergy to barrier and adhesive or an infection. Remeasure stoma before each change to ensure best fit of pouch. Change size of pouch opening as needed to protect skin.
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The nurse is caring for a client who is obese. Appropriate interventions related to nutrition for this client include: Standard Text: Select all that apply
1. BMI measurement. 2. Monitor weight weekly. 3. Record oral intake. 4. Limit client access to food. 5. Monitor skin for redness and breakdown.
A hospitalized patient complains of acute chest pain, which he rates as a 9 on a scale of 0 to 10 . The nurse administered a 0.4 mg sublingual nitroglycerin tablet, and now finds his vital signs to be stable. The nurse's next step is to
a. provide a second dose of nitroglycerin in 5 minutes. b. continue dosing at 10-minute intervals. c. obtain a transcutaneous pacer. d. increase the dose to 1 mg.
The parents of a 4-year-old who is a picky eater ask the nurse what foods to include in their child's diet to provide adequate iron consumption. Which food would the nurse recommend?
A) Cooked lentils B) Whole milk C) Oranges D) Sweet potatoes
The nurse is using electronic care planning. He enters the patient's nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals
When he considers the list of interventions that the program generates, he sees that none of them fits this patient's individual needs. What should the nurse do? a. Reject them all and type in appropriate interventions. b. Select the interventions from the program that are most suitable. c. Ask another nurse to assess the patient and give her recommendation. d. Restart the computer; it is probably a program malfunction.