What is the most important information concerning elimination to assess for the client who is to undergo rehabilitation?
A. What was the client's usual bowel elimination pattern before the injury or illness?
B. Does the client have at least one bowel movement each day?
C. Can the client transfer from the wheelchair to the toilet?
D. Does the client have diarrhea?
A
Rehabilitation strategies for bowel training or habits are established based on what is normal for that specific client.
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Which condition is a priority for the nurse planning care for a patient with exfoliative dermatitis?
A) Fluid volume deficit B) Self-image issues C) Comfort D) Altered nutrition
The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is:
1. A reduced skin elasticity is common in the older adult 2. The attachment between the epidermis and dermis is weaker 3. The older client has less subcutaneous padding on the elbows 4. Older adults have a poor diet that increases risk for pressure ulcers
A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.)
a. Do not rinse. b. Clean under breasts. c. Inform that the skin will feel sticky. d. Dry thoroughly between skin folds. e. Use two wipes for each area of the body.
While auscultating fetal heart tones, a client who is at 37 weeks' gestation and is in the supine position is experiencing dizziness, lightheadedness, and clammy skin. Which nursing action is the most appropriate?
1. Administer supplemental oxygen. 2. Help the client turn onto her right side. 3. Place a wedge beneath the client's right hip. 4. Prepare for administration of packed red blood cells (PRBCs).