The nurse applies a warm moist compress to the client's left wrist. Which item should the nurse exclude from the documentation of the intervention for this client?
1. Assessment of site before and after the application
2. Client's response to the compress
3. Assessment of the site every 5–10 minutes
4. Vital signs before, during, and after the treatment
4
Rationale 1: The site should be assessed before and after application of heat.
Rationale 2: The client's response should be documented.
Rationale 3: The site should be assessed every 5 to 10 minutes.
Rationale 4: Although it is never wrong to monitor vital signs, it is only required when heat is applied to a large area of the body. Heat applied to only the wrist should not impact vital signs, and would not be required unless the client showed an unexpected response.
Global Rationale: Although it is never wrong to monitor vital signs, it is only required when heat is applied to a large area of the body. Heat applied to only the wrist should not impact vital signs, and would not be required unless the client showed an unexpected response. The site should be assessed before, after, and during the treatment. The client's response should be documented,.
You might also like to view...
Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should nurses identify?
Select all that apply. A) Medication effects B) Overdependence on assistive devices C) Poor lighting D) Sensory impairment E) Ineffective use of coping strategies
A dying client's family members are spending time with the client. What instruction is best to give to family members regarding noise in the client's room?
a. "Remember that she cannot hear you." b. "Try to get her to talk or respond to you." c. "Avoid making any noise when you are with her." d. "Talk in your normal speaking voice."
Which statement made by a client whom the nurse is teaching how to self-inject insulin reflects a need for clarification of injection site selection and rotation?
A. "The abdominal site is best because it is closest to the pancreas." B. "I can reach my thigh the best, so I will use different areas of the same thigh." C. "By rotating the sites within one area, my chances of having tissue increases or decreases is less." D. "If I change injection sites from the thigh to the arm, the rate of absorption will be different."
A nurse provides an opioid antidote to a patient experiencing opioid toxicity. Which of the following is expected?
a. Tachypnea b. Confusion c. Pain d. Sedation