The nurse encourages the labor client to void at least every 2 hours, primarily because a distended bladder may:
a. cause severe pain
b. impede fetal descent
c. result in bladder trauma during the birth process
d. result in kidney infection from stasis of urine
B
The renal system responds as the client's distended bladder may slow the descent of the fetus. Pressure from the presenting part may cause edema of tissues and decreased urinary flow. It may also reduce the client's urge to void.
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A child is being weaned from the ventilator. He is awake and alert but getting increasingly tired. Which action by the nurse is the most appropriate?
A. Cluster nursing care so the child is able to get uninterrupted periods of rest. B. Collaborate with other health team members to slow or stop the weaning process. C. Draw a blood sample for blood gas analysis, and compare the results to the last blood gas values. D. Have all of the child's visitors leave to allow the child to take a short nap.
Nebulized albuterol should be available to counteract anaphylactic shock. This drug
A) counteracts hypotension. B) facilitates breathing. C) depresses the central nervous system. D) increases the pulse rate.
A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following statements best reflects an understanding of client-centered goals?
1. "The client's A1C levels will be 7 or below at the first testing date." 2. "The client will experience no blood sugar readings below 60 mg/dL before first follow up visit." 3. "The client will be visited weekly by home health nursing staff beginning 1 week after discharge." 4. "The client will demonstrate the ability to appropriately measure blood sugar lev-els using a glucometer by discharge from nursing unit."
Moist heat applications are used to
A) reduce tissue swelling. B) relax muscles. C) relieve pain. D) all of the above