A health care provider orders that a confused and disoriented patient be placed in a full hand restraint because of excessive scratching of skin. The nurse acknowledges which of the follow-ing?
a. Restraints are used on an as-needed basis.
b. No orders or patient consents are needed.
c. Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition.
d. An order for restraints may be used inde-finitely until the patient no longer needs to be restrained.
C
Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition. Restraints are only used when other less restrictive measures fail to prevent interruption of thera-pies. The physician's or health care provider's orders are necessary. The need for restraints must be reevaluated every 24 hours.
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Which factor was the most significant feature associated with district nursing?
A) Caring for the sick B) Teaching hygiene and cleanliness C) Preventing illness D) Gathering statistical data
A woman with a history of heart failure is in labor and has the following vital signs: blood pressure: 100/58 mm Hg, pulse: 120 beats/minute, respiratory rate: 36 breaths/minute, oxygen saturation: 88%. Which action should the nurse perform first?
A. Administer oxygen at 10 L/min per rebreather mask. B. Call the health-care provider to report the results. C. Document the findings in the patient's chart. D. Increase the woman's IV infusion to 150 mL/hour.
The nurse demonstrates therapeutic use of self when performing what nursing intervention?
1. Sitting with a dying patient 2. Attending class 3. Studying for a test 4. Learning the nursing code of ethics
The nurse is teaching new nursing assistants on the unit about the phenomenon of muscle hypertrophy. Which of the following clients on the unit is most likely to experience muscle hypertrophy? A client with
A) urinary incontinence following a cerebral vascular accident (CVA). B) hypertension, obesity, and decreased activity tolerance. C) peripheral edema secondary to heart failure (HF). D) possible rejection symptoms following a liver transplant.