The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which of the following interventions are appropriate? (Select all that apply.)
A. Place a small pillow between bony surfaces.
B. Elevate the head of the bed to 45 degrees.
C. Limit fluids and proteins in the diet.
D. Use a lift sheet to assist with repositioning.
E. Reposition the client who is up in the chair every 2 hours.
F. Keep the heels off the bed surfaces.G. Use a rubber ring to decrease sacral pressure when up in the chair.
A, D, F
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When you go to a patient's room to give morning care, you notice that she is reading a Bible. What should you do?
A) Ask her what religion she practices B) Ask if she wants you to come back in 15 minutes C) Tell her that her morning care will only take a few minutes and then she can return to her reading D) Leave the toilet articles on her table for her to use later
When treating a client for a sprained ankle, the nurse wraps the client's ankle in a bandage. What is the purpose of wrapping the client's ankle in a bandage?
A) Maintains a moist environment B) Maintains an aseptic environment C) Holds topical medication in place D) Limits movement in the wound area
The nurse is aware that the process by which capillary permeability is altered to allow the large neutrophils to pass through the capillary wall and to the wound site is called
a. banding. b. marginating. c. replicating. d. segmenting.
The nurse is instructing a patient who has a hearing and balance disorder. What should be included in these instructions?
Select all that apply. 1. Change positions slowly. 2. Turn the whole body, rather than just the head. 3. Stand very still with the onset of vertigo. 4. Increase pace of ambulation. 5. Avoid reclining while taking antivertigo medication.