Which of the following is likely to result in damage to the client's skin? (Select all that apply.)
1. Dry shaving a client in preparation for discharge
2. Removing the tape when discontinuing a heparin lock
3. Frequently positioning the client on her favorite right side
4. Applying moisturizing lotion on the heels of a diabetic client
5. Elevating the bed to 85 degrees so the client can easily watch a movie on TV
6. Waiting until the mechanical lift is available to transfer an immobile client
ANS: 1, 2, 3, 5
Weakening of the epidermis occurs by scraping or stripping its surface (e.g., use of dry razors, tape removal, or improper turning or positioning techniques). The remaining options are not likely to cause skin damage
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A nurse is documenting the types of high-risk newborns on the unit. Which infants would be classified as preterm? (Select all that apply)
A. weeks B. weeks C. weeks D. weeks E. weeks
The nurse includes in the discharge teaching of a patient who has had a lithotripsy that the patient should:
1. check for edema of the legs and ankles. 2. watch for stone debris in the urine in 1 to 4 weeks. 3. decrease fluid intake to 1000 mL/day. 4. remain on restricted activity for a week.
The appropriate tool(s) to assess pain in a 3-year-old child is the (select all that apply)
a. Visual Analogue Scale (VAS) b. Adolescent and pediatric pain tool c. Oucher tool d. Poker Chip Tool e. FACES pain rating scale
The nurse finds a patient sitting in bed, rocking back and forth, wringing her hands and repeating rapidly, "I can't breathe. My heart is pounding. I think I'm going to die."
Her physician is called to the bedside and tells the nurse, "She is having an anxiety attack." What assessment can be made by the nurse? a. Severe anxiety is present in this patient. b. Cultural factors control anxiety levels. c. Focusing on discharge instruction will ease the anxiety. d. The level of anxiety cannot be determined at this point.