A new parent asks the nurse, "How can diaper rash be prevented?" What should the nurse recommend?
a. Wash the infant with soap before applying a thin layer of oil.
b. Clean the infant with soap and water every time diaper is changed.
c. Wipe stool from the skin using water and a mild cleanser.
d. When changing the diaper, wipe the buttocks with oil and powder the creases.
ANS: C
Change the diaper as soon as it becomes soiled. Gently wipe stool from the skin with water and mild soap. The skin should be thoroughly dried after washing. Applying oil does not create an effective barrier. Over washing the skin should be avoided, especially with perfumed soaps or commercial wipes, which may be irritating. Baby powder should not be used because of the danger of aspiration.
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The nurse would determine that a client with menorrhagia is at risk for significant blood loss if the client reports changing the perineal pad or tampon at least every
a. 1 to 2 hours. b. to 3 hours. c. 4 to 5 hours. d. 6 to 8 hours.
The client's resuscitation lasts 30 minutes. The client's ECG shows ventricular fibrillation and the client has no pulse or blood pressure. Which does the nurse use to determine when this code should end?
1. According to the nursing unit policy 2. After 30 minutes of unresponsiveness 3. When instructed by the provider to stop 4. After futile results from vasoactive drugs
The functions of the major histocompatibility complex (MHC) and CD1 molecules are alike because both do what?
a. Are antigen-presenting molecules b. Bind antigens to antibodies c. Secrete interleukins during the immune process d. Are capable of activating cytotoxic T lymphocytes
T.M. returns to your unit the next afternoon from the postanesthesia care unit (PACu). He is in a bilateral
spica cast, has a Foley catheter, and has a family-controlled patient-controlled analgesia (PCA) device for pain control. You assess T.M. and chart the following findings. What are your top five priorities while providing nursing care to T.M. postoperatively? How will you address these areas?