The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?
a. Two full-length rails
b. One -length rail
c. No side rails
d. Four -length rails
B
The use of one -length rail is not considered a restraint; it can be used to assist the patient in get-ting in and out of bed. Two full-length rails and four -length rails would be considered a restraint. The use of no side rails is not considered a restraint; however, the use of one rail to maneuver in and out of bed may be most beneficial to the patient.
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A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.)
a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing
Which of the following best explains why cancer rates increase as people get older?
a. Better prevention programs are available for cardiac disease, so cardiac disease rates are decreasing, making cancer rates increase. b. It is harder to screen for cancer than for other fatal diseases, so the rates are increasing because of the inability to detect the cancer at an early stage. c. Poor lifestyle choices, environmental exposures, and increased life expectancy have all caused cancer rates to increase. d. Other causes of death are decreasing, so it appears that cancer rates are increasing.
When the 16-year-old patient with acute glomerulonephritis complains of boredom with bed rest and asks when he can become more active, the nurse states that bed rest will continue until:
1. dialysis starts. 2. antibiotic protocol is completed. 3. potassium levels are normal. 4. the blood pressure reaches normal levels.
A male patient admitted with a gastrointestinal bleed and a hematocrit level of 40% receives fluid resuscitation. In a few hours, the hematocrit level drops to 32%. How should the nurse evaluate this finding?
1. It is very likely that this patient has underlying renal disease. 2. There must be an undiagnosed second site of bleeding. 3. The patient is experiencing hemodilution caused by fluid resuscitation. 4. Efforts to stop the bleeding have not been successful.