A patient with a urinary diversion device is at risk for impaired skin integrity. Which intervention should the nurse perform for this patient?
1. emptying the bag reservoir every 2 hours
2. changing urine collection device every other day
3. teaching self-catheterization technique
4. monitoring for foul-smelling urine
Correct Answer: 1
Overfilling the collection bag can damage the seal, allowing leakage and contact of urine with the skin. The urine collection device is changed as needed. Teaching self-catheterization technique is not an appropriate intervention for this problem. Monitoring for foul-smelling urine does not help with the risk for impaired skin integrity.
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A client is being treated for extensive burns over much of the body. For which reason should the nurse expect to administer extra fluids to this client?
a. The wounds are exudative and contribute to fluid loss b. The client has lost a significant amount of body weight c. The remaining skin is dry from heat exposure and needs moisture d. The client is confined to bed and must rely on nursing care to meet essential needs
The nurse palpates a very weak pedal pulse in the right foot. What other findings would the nurse expect to find in the right foot and leg? (Select all that apply.)
a. Bruising b. Darkened color c. Cool skin d. Diminished hair on limb e. Capillary refill of 3 seconds
The nurse taking a continuing education course in intimate partner violence (IPV) learns what information about the roots of this violence? (Select all that apply.)
a. Female subservience b. Male dominance c. Money imbalances d. Societal gender attitudes e. Unequal social power balance
A client has a slight shift to the left on the oxygen-hemoglobin dissociation curve. Which of the following assessment findings will support this curve configuration?
1. Arterial pH less than 7.35 2. Increased levels of 2,3-diphosphoglycerate 3. Hyperthermia 4. Hypothermia