A nurse is developing a nursing plan of care for a client at risk for a pressure ulcer. Which of the below should be included in the plan? (Select all that apply.)
a. Perform a skin risk assessment.
b. Place a plastic sheet on the bed to protect the mattress.
c. Allow the client to sit on the bedpan for as long as the client feels the need to void.
d. Place a pressure-relieving mattress on client's bed
e. Apply a moisture barrier cream to client after each incontinent episode.
A, D, E
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The nurse has withdrawn medication from a vial for injection. Which of the following should the nurse do next?
a. Wash the hands. b. Follow the organization's policy regarding recapping and changing the needle prior to injecting. c. Label the syringe with drug, dose, date, and time. d. Prepare the client's other medications.
Identify the appropriate interventions for a patient with hypovolemia. Select all that apply
a. Teach deep-breathing techniques. b. Monitor I&O daily. c. Encourage fluid intake. d. Monitor electrolyte balance.
When the young AIDS patient complains of debilitating night sweats, the home health nurse suggests that he go to the clinic for:
1. a prescription for antibiotics. 2. a TB screen. 3. complete blood count. 4. treatment with an aerosol inhalant.
An apical PMI palpated beyond the fifth intercostal space may indicate:
a. decreased cardiac output. b. obesity. c. left ventricular hypertrophy. d. hyperventilation.