The nurse providing medication through a client's nasogastric tube should flush the port to:
a. prevent aspiration of medication. c. prevent clogging of the tube.
b. dilute the medication. d. increase the water intake.
ANS: C
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The patient has a very large burn involving the deep dermis and is being cared for in a reverse isolation environment. The family is very annoyed by the need to don gowns and masks to visit the patient. What is the best rationale for this rule?
A) It is the policy of the unit and hospital. B) It protects the family from infection. C) The patient is at increased risk for life-threatening infection. D) It protects the family from odors.
How should you respond to the above patient?
A. Encourage her to finish her exercise session. B. Interrupt her and have her weighed immediately. C. Tell her she is not allowed to exercise. D. Interrupt her and encourage her to take a walk with you.
A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the client's lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply?
A. "The cuff has to be placed on the leg because both arms are used for intravenous fluids." B. "The cuff functions to prevent succinylcholine from reaching the foot." C. "The cuff position gives a more accurate blood pressure reading during the treatment." D. "The cuff is placed on the leg so that arms can easily be restrained during seizure."
The nurse notes that the patient's skin is reddened, with a small intact serum-filled blister. How should the nurse classify this stage of ulcer formation?
a. Stage I b. Stage II c. Stage III d. Stage IV