During the morning bath of a client, the nurse identifies areas of erythema below the client's breasts. What should the nurse do to enhance comfort and healing for the client?
1. Wash the skin carefully.
2. Apply alcohol-free lotion.
3. Wash the area without soap.
4. Remove hair in the area.
Correct Answer: 1
Rationale 1: For areas of erythema, the nurse should wash the area carefully to remove microorganisms.
Rationale 2: Alcohol-free lotion would be applicable for excessively dry skin areas.
Rationale 3: Washing without soap would be applicable for excessively dry skin areas.
Rationale 4: Removing the hair would be applicable for hirsutism.
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A patient's potassium level is 6.5 mEq/L. The nurse would prepare for which intervention?
1. Administration of intravenous fluids supplemented with 40 mEq of potassium in each liter of fluid 2. Administration of oral potassium 2 or 3 times daily until levels are normal 3. Administration of Kayexalate 4. Administration of a D50W bolus
The nurse would anticipate laboratory values from a patient in ketoacidosis to reveal:
a. increased blood urea nitrogen (BUN). b. normal or decreased CO2. c. increased arterial pH. d. decreased glucose.
An indwelling urinary catheter is inserted for a woman with a high spinal cord injury who has had a cesarean birth. As you walk into her room, you notice her face is reddened and she says she has a sharp headache
You take her blood pressure and discover it is 160/120 . Which of the following would you do first? A) Lower her head and ask her to breathe slowly in and out. B) Raise her head and assess the catheter for blockage. C) Immediately cut and remove the indwelling catheter. D) Sit her up abruptly and massage her lower back.
Which of the following client statements below is most suggestive of ineffective management of a therapeutic regimen?
1. "I want to follow my new diet, but it doesn't provide enough food. I still feel hungry after I eat." 2. "I've decided that it's better for me to continue to prepare food as I have always done." 3. "The new diet is too expensive. I will not spend all of my money on food." 4. "Preparing and eating certain foods cannot be that effective in keeping me well."