An intubated patient, with one leg and arm cast, needs to be weighed. Which of the following should the nurse do to gain the most accurate information about the patient's weight?
1. use a bed scale and measure the patient's weight
2. use a bed sling and measure the patient's weight
3. measure current weight and research the patient's "usual" weight to estimate the correct weight
4. ask a family member what the patient usually weighs
3
Rationale: The measurement of weight in an intensive care unit might be compromised due to the presence of casts, tubes, drains, and other devices which might falsely inflate the patient's weight. In such cases, weight measurement becomes relative; that is, current weights are compared to previous weights, and the patient's ‘usual' weight, if possible, to identify obvious weight gains or losses. The nurse should measure the patient's current weight, find out the "usual" weight, and then estimate the closest correct weight. Using the bed scale or bed sling will not take into consideration the patient's casts. The family member might not know the patient's usual weight.
You might also like to view...
The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, the nurse would find that the extremity:
1. Has a capillary refill of greater than three seconds. 2. Is warm, with a capillary refill of less than three seconds. 3. Has decreased sensation with a weakened dorsalis pedis pulse. 4. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse.
The patient talks with his dead brother and arranges furniture so that his brother will have a place to sit. How should the nurse document this behavior?
a. Disordered thinking b. Anhedonia c. Hallucination d. Alogia
If a reviewer is asking "Is it related to nursing's body of knowledge?", what part of the study is being critiqued?
a. Literature review b. Research objectives, questions, or hypotheses c. Research problem and purpose d. Study framework
The theory that views the family as a whole with boundaries that are affected by the environment is:
1. Developmental theory 2. Structural-functional theory 3. Role theory 4. Systems theory