The nurse is caring for a 10-year-old in traction. While performing a skin assessment, she notices that the skin over the calcaneus appears slightly red and irritated. Which of the following should be the first intervention?
A) Reposition the child's foot on a pressure-reducing device.
B) Apply lotion to his foot to maintain skin integrity.
C) Make sure the skin is clean and dry.
D) Gently massage his foot to promote circulation.
A
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Which of the following is a holistically based nursing intervention for the nursing diagnosis Impaired Gas Exchange related to immobility?
A) Teach and encourage turning B) Feed in the sitting position C) Apply oxygen as needed D) Demonstrate signs of adequate respiration
The nurse is assessing the client's respiratory system. Which of the following methods will result in the most accurate assessment of the client's respiratory rate?
1. The nurse should place a hand on the client's chest to count respirations accurately. 2. The nurse should inform the client that the nurse is counting the client's respirations. 3. The nurse should count only the respirations that are audible. 4. The nurse should count the respirations in an unobtrusive manner without informing the client.
A newborn's 1-minute Apgar score was 9. Which of the following criteria is most likely responsible for the loss of 1 point from a possible score of 10?
a. Heart rate b. Respiratory effort c. Color d. Muscle tone
A nurse is teaching a client about bethanechol hydrochloride (Urecholine). The nurse informs the client that this drug warrants which precaution?
a. Rising slowly from lying positions b. Counting pulse rate frequently to assess for bradycardia c. Avoiding diarrhea by eating binding foods d. Maintaining aspiration precautions because of excess saliva