What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply.)
a. Turn the patient to his right side
b. Change dressing as it becomes soiled
c. Turn patient every 2 hours
d. Leave the bed flat
e. Medicate immediately on the complaint of nausea
ANS: A, D, E
The bed is left in the flat position and the patient is positioned with the operated side facing up, the patient is not turned, and the dressing is not changed by the nurse. The patient should be medicated immediately on complaint of nausea to prevent vomiting and possible disruption of graft.
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A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?
a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Client's weight decreased by 3 pounds
A patient who has been casted for a fracture of the left ulna asks the nurse when the cast will come off. The nurse's response is based on the knowledge that the cast will be removed when which physiologic parameter has been met?
1. The remodeling phase of the bone healing process has been completed, allowing for application of mechanical stress. 2. A cartilage collar can be clearly felt at the site of the original break. 3. A specific amount of time has passed, predetermined by the severity of the break. 4. The X-ray of the fractured bone shows that the ends are well joined.
Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically, this expression refers to:
1. formally initializing individualized care by confirming the woman's and infant's ID numbers on their respective wrist bands ("This is your baby"). 2. teaching the mother to check the identity of any person who comes to remove the baby from the room ("It's a dangerous world out there"). 3. including other family members in the teaching of self-care and child care ("We're all in this together"). 4. nurturing the woman by providing encouragement and support for her taking on the many tasks of motherhood.
The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately?
1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan