The nurse is working on a care area that focuses on tertiary prevention. Which goal is consistent with this focus?
1. Patients at risk for skin breakdown will be turned every 2 hours.
2. Patients with pressure ulcers will have whirlpool therapy as indicated.
3. Patients are assessed for factors that place them at risk for skin breakdown.
4. Patients are instructed to move in bed at least every 2 hours to prevent skin breakdown.
2
Rationale: Turning a patient at risk for skin breakdown is an example of a primary prevention goal.
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A nurse is providing care for a client who is immunocompromised following chemotherapy. The nurse knows which of the following characterizations of the adaptive immune system listed below is responsible for the client's disruption in his normal immune fun
A) Epitopes on antigens are recognized by immunoglobulin receptors following presentation by accessory cells. B) Haptens combine to form epitopes that stimulate the response of regulatory and effector cells. C) Effector cells orchestrate the immune response of regulatory cells toward an antigen. D) Accessory cells such as macrophages are engulfed by regulatory cells, stimulating effector cells.
An elderly client is scheduled for cataract surgery and asks the nurse, "Will I need to wear pop-bottle lenses after surgery?" Which is the most appropriate response from the nurse?
A) "An implanted lens has replaced the need for corrective glasses." B) "Contact lenses are preferred by most clients after this surgery." C) "They can make corrective lenses much thinner now." D) "No lens is necessary with cataract surgery."
The client asks the nurse what the medical term for a slow heart rate is. Which response by the nurse is the most appropriate?
1. "Atrial fibrillation." 2. "Bradycardia." 3. "Premature ventricular contraction." 4. "Tachycardia."
A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patient's lungs?
a. Vesicular breath sounds heard in peripheral lung fields b. Bronchial breath sounds heard over the bronchi c. Bronchovesicular breath sounds heard over the apices d. Rhonchi heard over the main bronchi