A nurse is caring for a child with nephritic syndrome who is severely edematous and has been placed on complete bed rest. Which of the following is a priority intervention for this client?
1. Reposition the child every two hours
2. Monitor blood pressure every 30 minutes
3. Encourage fluids
4. Limit visitors
1. Reposition the child every two hours
Rationale:
A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every two hours. Vital signs are taken every four hours. Fluids need to be monitored and should not be encouraged. The child needs social interaction, so visitors should not be limited.
You might also like to view...
A client with diabetes mellitus can effectively monitor the blood sugar at home. The nurse should encourage the client with type 1 diabetes mellitus to monitor:
1. indirect blood glucose monitoring. 2. direct blood glucose monitoring and urine testing for glucose and ketones. 3. hemoglobin A1c testing. 4. home cholesterol testing.
A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wartlike lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding?
A) Testing the client for the presence of HIV B) Instructing the client to wear cotton underwear C) Having the client abstain from sexual activity for 6 weeks while the medication is working D) Using a medicated douche in order to keep the vaginal pH normal
The nurse is admitting a patient with heart disease to the cardiac unit. When answering questions related to his health history, the patient's responses are lengthy and time consuming. What is the most important action by the nurse?
a. Recognize the patient may be lonely and just wants to talk to someone b. Set a time limit and inform the patient of your time frame to complete the assessment c. Anticipate the patient answers and quickly go on to the next question d. Be attentive, focus on what the patient has to say, and respond accordingly
What should be included at the end of the documentation entry in an individual's record?
a. A signature. b. A designation. c. A name. d. All of the above.