The nurse assesses the stoma of a client who has an ureterostomy and observes fine white crystals around the stoma. Which should the nurse implement?
1. Brush away the crystals with a cloth.
2. Apply a new, well-fitting skin barrier.
3. Increase the dietary protein and fluids.
4. Cleanse with a warm vinegar solution.
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4. The nurse cleanses the peristomal area with a weak vinegar and warm water solu-tion because vinegar is a mild acid (acetic acid), dissolves the crystals, and does not irritate the skin.
1. The nurse avoids brushing away the crystals with a dry cloth because this poten-tially causes tissue trauma.
2. The nurse cleanses around the skin barrier; replacing the skin barrier is unnecessary as long as it is not leaking.
3. Increasing dietary protein and fluids is not indicated for this problem.
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An appropriate ongoing, long-term treatment goal for a victim who experienced sexual abuse eight months ago is to:
1. Establish rapport and build a trusting nurse–client relationship. 2. Move from victim to survivor status. 3. Become aware of legal rights. 4. Involve significant others in the treatment plan.
The nurse positions the client on the sling, wheels the lift into position, and connects the sling to the lift. Which are priority safety measures prior to lifting the client?
Select all that apply. 1. Locking the wheels of the lift 2. Opening the base to the widest position 3. Lowering the side rails 4. Checking that the hooks are correctly placed and that matching chains are of equal length 5. Facing the hooks toward the client
A nursing student asks the clinic nurse why it is important to find out whether a woman in a violent relationship feels safe leaving the clinic. The best response by the nurse would be to tell the student that
a. femicide is a major cause of death, especially in African American women. b. if the woman is not safe, the nurse can have the police escort her. c. the law requires asking about patient safety in this situation. d. women who are not safe need to be given referral information.
The nurse is presenting a class for pregnant women. What would the nurse include related to the head and neck?
A) Get regular examinations including B12 screening B) Get regular examinations including folic acid screening C) Get regular examinations including thyroid screening D) Get regular examinations including amniocentesis screening