The nurse is assessing a client's respirations. Characteristics of costal breathing include: (Select all that apply)
1. Use of external intercostal muscles
2. Contraction of diaphragm
3. Use of accessory muscles
4. Movement of abdomen
5. Movement of chest upward and outward
1,3,5
Rationale: Thoracic (costal) breathing involves the use of external intercostal muscles
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The nurse is administering a back massage to the client. Place the steps in the proper order of performance
Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Massage the areas over the right and left iliac crests. Response 2. Move your hands up the center of the back. Response 3. Massage the sacral area using smooth, circular strokes. Response 4. Massage both scapulae. Response 5. Move your hands down the side of the back.
The nurse admitting a client to a same day surgery unit makes the decision to notify the surgical team to cancel the procedure based on the client's statement that:
a. "Will I start taking my St. John's wort as soon as I can eat again?" b. "I've haven't taken my ginkgo for exactly 10 days." c. "I didn't want to risk catching a cold so I took my echinacea with just a sip of wa-ter." d. "It seemed strange not taking my garlic pill this morning."
The nurse is instructing a young patient on avoiding toxic shock syndrome. Education was successful when the patient states: Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply
1. "I will wash my hands before inserting a tampon.". 2. "I will change my tampon every 3–6 hours.". 3. "I will not touch the part of the tampon I insert.". 4. "I will just put the used tampon in the trash.". 5. "I will take prophylactic antibiotics if needed.".
The nurse observes fruity breath in an individual with diabetic ketoacidosis. Which of the following may also be observed?
a. Pallor. b. Kussmaul's breathing. c. Bradycardia. d. Clammy skin.