A client has been hospitalized following a myocardial infarction. The client has an IV line run-ning with multiple drips
The nurse assesses the client's medical record to determine the last time the IV tubing was changed, because the nurse knows that the Centers for Disease Control and Prevention (CDC) recommends that IV tubing be changed:
1. Every shift
2. Daily
3. Every 48 hours
4. Every 72 hours
ANS: 4
CDC and INS recommend tubing change no more often than 72-hour intervals or whenever tub-ing has been compromised. The more frequently a closed sterile system is opened, the more op-portunities there are for microorganisms to be introduced into the system.
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A client is being discharged with a tracheostomy and voices concern about his appearance. What discharge teaching will assist the client with maintaining a positive body image?
a. "Tell people how sick you were when they ask about the tracheostomy." b. "Your clothing can help hide the tracheostomy so it is not as noticeable." c. "You can put a bandage around your tracheostomy so no one will see it." d. "You have to ignore comments that people make about your appearance."
Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy?
a. Blood in urine b. Left flank bruising c. Left flank discomfort d. Decreased urine output
A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries
How should the nurse explain these different responses to stress to the parents? A. Reactions to stress are relative rather than absolute; individual responses to stress vary. B. It is abnormal for identical twins to react differently to similar stressors. C. Identical twins should share the same temperament and respond similarly to stress. D. Environmental influences weigh more heavily than genetic influences on reactions to stress.
A nurse is caring for a young client addicted to drugs. The family is in the adjustment phase of coping with stress. Which is identified with the adjustment phase?
A) Family and community provide assistance B) Family may accept demands created by the stressor C) Patterns of behavior within the family are altered D) Family realizes the need for change in the family structure