Which of the following interventions would be appropriate for a client recovering from a splenectomy?
1. Assist with ambulation once per shift.
2. Medicate for pain.
3. Utilize strict infection control techniques.
4. Encourage the client to deep breathe and cough every 8 hours.
3
Removal of the spleen often results in life-threatening infections known as overwhelming postsplenectomy infections. The nurse should utilize strict infection control techniques when providing care to this client. Ambulation and medicating for pain would be appropriate for any client recovering from surgery. Deep breathing and coughing should be done more frequently than every 8 hours.
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The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education?
a. "I should report any complaints of soreness to the nurse." b. "I should watch for indications that the patient has difficulties using the cane." c. "I should let the nurse or PT know if the cane doesn't seem to fit correctly." d. "I should teach the patient how to walk with the cane."
Ana is admitted to the medical surgical floor for severe weight loss. Her diagnosis is anorexia nervosa. She is 16 and looks about 8. Her daily intake is about eight cans of diet soda. Your initial nursing goal is:
A. Establish trust. B. Request nutritional supplements from Dietary. C. Explore with her the rationale for refusing to eat. D. B and C
The physician ordered a beta blocker for a client. The nurse checks vital signs for this client. Which vital sign would cause the nurse to question administering the medication?
1. Temperature 99.4°F 2. Blood pressure 148/62 3. Respirations 18 breaths per minute 4. Pulse 48 beats per minute
During the process of endocytosis, the phagosome step results in:
a. Microorganisms are ingested. b. Microorganisms are killed and digested. c. Phagocytes recognize and adhere to bacteria. d. An intracellular phagocytic vacuole is formed.