When changing the soiled linen on the bed of a client who is comatose, the nurse notices a red-dened, blanchable area approximately 2 cm in diameter on her left buttock. The nurse's initial skin breakdown intervention is to:
1. Position the client on her right side
2. Finish providing fresh, dry linen to the client's bed
3. Include a 2-hour turning schedule in the client's care plan
4. Measure the area in order to describe it in the nurses' notes
ANS: 1
Pressure is the major cause in pressure ulcer formation, and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pres-sure. The remaining options are appropriate, but none has priority over proper positioning of the client.
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Which statement by a nurse indicates an understanding of online nurse education programs? (Select all that apply.)
a. The online programs are less work that face-to-face programs. b. The online program provides education for adults who cannot relocate to continue their education. c. The online program requires no travel. d. Online nurse education programs only of-fer an associate's degree in nursing. e. Online nursing education programs are only for advanced practice and doctoral programs.
The parent of a child taking methylphenidate (Ritalin) asks the school nurse what medications can be used to help alleviate the child's allergies. The nurse replies, "While your child is taking this medication, you should avoid giving:
A) Strawberries." B) Acetaminophen." C) Antihistamines." D) Ibuprofen."
The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, "This has been happening more often after I eat rich, high-fat foods." Which question should the nurse include in the history?
A. "Do you have a history of pancreatitis?" B. "Do you have a history of gastritis?" C. "Do you have a history of cholecystitis?" D. "Do you have a history of a duodenal ulcer?"