The nurse is reviewing the plan of care for a client with delirium. Which interventions will the nurse include in the care for this client? Select all that apply.
A) Apply arm restraints to prevent self harm
B) Allow client to eat alone during mealtimes
C) Provide a calm, well-lit environment
D) Reduce sound in the client's room at night
E) Avoid constant observation to increase autonomy and security
C) Provide a calm, well-lit environment
D) Reduce sound in the client's room at night
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A patient is receiving an IV infusion of lactated Ringer's solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish
The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following? a. Infiltration b. Extravasation c. Hematoma d. Phlebitis
Which of the following conditions would predispose a client for thrombophlebitis?
1. Severe anemia 2. Cesarean delivery 3. Anorexia 4. Hypocoagulability
You are performing a skin puncture using a fingertip. Which is correct?
a. Cool the finger with an ice pack. b. Raise the finger above the person's waist. c. Clean the site with an antiseptic wipe. d. Touch the site after cleaning to ensure you have the correct site.
After teaching a group of students about the structure and function of the skin, the instructor determines that the teaching was successful when the students identify which of the following as responsible for variations in skin color?
A) Sebaceous glands B) Keratin C) Melanin D) Eccrine glands