In assisting a male patient in using a urinal, which of the following actions should the nurse take? (Select all that apply.)
a. Assess for orthostatic hypotension.
b. Assess the patient's normal elimination habits.
c. Assess for periods of incontinence.
d. Prop the urinal in place if the patient is unable to hold it.
e. Always stay with the patient during urinal use.
A, B, C
To assist the patient in using a urinal, the nurse should assess the patient's normal urinary elimination habits and look for periods of incontinence. Always determine mobility status before having a patient stand to void, and assess for orthostatic hypotension if the patient has been on prolonged bed rest. If the patient is able to handle the urinal himself, allow him privacy. If the patient is unable to handle the urinal the nurse will assist by holding it.
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A nurse is teaching a woman about pain management strategies during labor. The woman expresses great fear about the experience. Which of the following statements by the nurse would help to ease the woman's fears? (Select all that apply.)
A. "Don't worry about the pain; at least it's not from illness." B. "Keep in mind there is an end to the pain with the birth." C. "Pain during labor is normal and expected, and helps you to give birth." D. "We can anticipate your labor pain and plan for it." E. "You have to expect some amount of pain during labor."
Before the physician performs an external version, the nurse should expect an order for a:
a. Tocolytic drug. b. Contraction stress test. c. Local anesthetic. d. Foley catheter.
The client is receiving cyclophosphamide, doxorubicin, and vincristine as chemotherapy for lung cancer. At the second round of therapy, the client tells you that a lot of blood was in the urine for 3 days after the therapy
What is your best action? A. Obtain a urine specimen for culture and sensitivity. B. Document the information as the only action. C. Check the client's platelet count. D. Notify the physician.
A nurse documents the following assessment on an older adult client's chart: "dry, thin skin." Which of the following nursing diagnoses would be appropriate for this client?
A) Risk for falls B) Risk for imbalanced body temperature C) Risk for infection D) Risk for sedentary lifestyle