Which of the following is a nursing implementation?
1. Auscultation of bowel sounds
2. Provide skin care and turn the client every two hours.
3. Report that the client is performing more of her own ADLs.
4. Documentation of redness on the client's elbow
2
Rationale 1: Providing skin care and turning the client are implementation activities. Auscultation and documentation of redness are part of the assessment process. Reporting that the client is performing more ADLs is an evaluation statement.
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A woman who is 8 months pregnant comments that she has noticed a change in her posture and is having lower back pain. The nurse tells her that during pregnancy, women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as:
a. Lordosis. b. Scoliosis. c. Ankylosis. d. Kyphosis.
You are evaluating the discharge teaching you have done with your patient concerning drug therapy. What statement from the patient would indicate that teaching had been effective?
A) "I have to take three pills each day and I can take them at the time that fits my schedule." B) "I should take the white pill in the morning because the doctor wants me to take it." C) "I will add the names and dosages of these new drugs to my medication list in my wallet." D) "I have prescriptions at different pharmacies. I shop around for the best price for each drug."
A patient with type 1 diabetes mellitus is admitted with hyperglycemia and dehydration, and is being evaluated for diabetic ketoacidosis. The nurse recognizes that which laboratory finding would support this diagnosis?
1. Potassium of 4.5 mEq/L 2. Anion gap of 20 mEq/L 3. Sodium of 140 mEq/L 4. Bicarbonate level of 36 mmol/L
A nurse observes that a patient diagnosed with bipolar disorder who has left the seclusion room is soiled with feces. Which nursing intervention would be most likely to encourage a patient to comply with bathing?
a. Say to the patient, "We are going to help you to bathe and freshen up.". b. Say to the patient, "Would you like to clean up and change your clothes?" c. Do nothing until the patient has enough personal control to realize the need. d. Return the patient to the room and reorient him or her to the bathroom and clean clothing.