As you make rounds, you notice that A.T.'s pouch has sprung a urine leak and she has placed
a washcloth over the pouch to absorb the urine. She asks you for tape to attach the washcloth
to the bag. How will you respond to her request?
What will be an ideal response?
tell her that her pouch needs to be changed because urine next to the skin can cause skin
breakdown. Urine exposure, even over a period of 24 hours or less, can cause skin breakdown that
will make it more difficult to achieve an intact pouch seal.
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A nurse explains that cardiac rehabilitation lasts from the end of acute care to the return to home and beyond. What does this service include?
a. One-on-one individualized care b. Focus on the patient rather than the family c. Telemetry-monitored exercise d. Rejection from the program for noncom-pliance
Which of the following is a nontherapeutic statement during the orientation phase of a relationship?
a. "I am the nurse who will be caring for you today." b. "My job is to make you better." c. "I will be talking with you while I provide care." d. "You will be receiving care from an assistant and myself."
The client received lispro (Humalog) insulin with breakfast. Two hours later, the client experiences tachycardia, confusion, sweating, and drowsiness. Why are these symptoms occurring?
1. The client is experiencing hyperglycemia. 2. The client is experiencing an allergic reaction to lispro (Humalog). 3. The client is experiencing a myocardial infarction. 4. The client is experiencing hypoglycemia.
Which is the priority action by the school nurse for an adolescent who drops to the ground and is unresponsive during a high school basketball game?
1. Initiating cardiopulmonary resuscitation (CPR) 2. Calling 911 3. Offering the parents comfort 4. Assessing for hemorrhage