The nurse on a rehabilitation unit is caring for a 77-year-old patient who had undergone total knee replacement surgery. Since surgery, the patient has had several instances of urinary incontinence
The health care provider is contemplating the order of a Foley catheter. What is the nurse's best response to this suggestion? a. "Perhaps you could order intermittent straight catheter insertions instead?"
b. "I think it would be better to put a disposable undergarment on her."
c. "Could we try a toileting schedule before you order the Foley?"
d. "I think that is a good idea; it will prevent skin breakdown."
C
You are in a strategic position to serve as a patient advocate by suggesting noninvasive alternatives to catheterization use. For example, you may decrease the risk for UTI by suggesting the use of a bladder scanner to evaluate bladder urine volume without invasive instrumentation or implement a toileting schedule for the incontinent patient. Be aware of indications for catheter insertion and be prepared to advocate for the patient if the indications do not meet accepted guidelines.
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The nurse is assessing the function of the client's cranial nerve XII (hypoglossal). Which activity will allow the nurse to assess this nerve during the client's physical assessment?
1. "Can you stick out your tongue?" 2. "I'm going to ask you to taste something and tell me what you think it is." 3. "Close your eyes and tell me when you feel me touch your face with this wisp of cotton." 4. "I'm going to lightly touch the back of your throat with this tongue depressor."
An older patient is accompanied to a physician's office visit with an adult daughter who walks with an assistive device. The older patient is hard of hearing, has osteoarthritis, and has difficulty completing activities of daily living
Which nursing diagnosis would the nurse identify as being the priority at this time? 1. Social isolation 2. Caregiver role strain 3. Ineffective protection 4. Situational low self-esteem
The nurse observes a healthy 13-year-old female throwing away lunch. This female could be at risk for developing:
a. disturbed body image c. malnutrition b. fluid volume deficit d. activity intolerance
Convert 0.85 to a fraction and reduce it to the smallest terms
1. 1/4 2. 11/19 3. 17/20 4. 45/50