A nurse is preparing an educational program on DVT prevention for her peers. Which of the following nursing interventions would the nurse include in her program? Select all that apply
A) Turn bed-bound clients at least every 2 hours.
B) Get older clients up and walking as soon as possible after surgery.
C) Teach older clients to not elevate their legs when sitting.
D) Urge older clients at risk for DVT to wear fitted support stockings.
A, B
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The nurse determines the risk for a pressure ulcer in an older adult who is 6 feet tall and weighs 155 pounds
Which patient information should the nurse use in planning care to reduce this individual's risk for a pressure ulcer? (Choose all that apply.) a. Osteoarthritis of neck b. Dry mucous membranes c. Prealbumin level 7 mg/dl d. Fasting glucose 140 mg/dl e. Serum sodium 135 mEq/dl f. Uses food stamps to get food
Breast self-examination is best when breasts are least congested and smallest. The nurse knows this would be what days of the menstrual cycle?
A) 1 to 3 B) 3 to 5 C) 4 to 7 D) 6 to 9
Which of the following statements accurately describe a step for inserting an oropharyngeal airway? Select all that apply
A) Use an airway that is the correct size (size 90 mm is appropriate for the average adult). B) Airway should reach from opening of mouth to the back angle of the jaw. C) Position patient on his or her stomach with neck hyperextended (unless this is inappropriate). D) Open patient's mouth by using your thumb and index finger to gently pry teeth apart. E) Insert the airway with the curved tip pointing up toward the roof of the mouth. F) Rotate the airway 360 degrees as it passes the uvula.
The nurse has been talking with a client who has a delusion about being the President of the United States. One day a ward mate challenges him by saying, "If you were the President, you would not be here."
Shortly afterwards the nurse hears the client explaining that because of the Iraq war, the CIA has had to hide him in a psychiatric unit, so his enemies would not find him. The nurse should recognize which of the following in the client's statement? A) Delusions of control B) Systematized delusion C) Thought insertion D) Thought withdrawal