The nurse is planning care for a client with disseminated intravascular coagulation to address ineffective tissue perfusion. Interventions appropriate for the client would include:
1. Encouraging deep breathing and coughing.
2. Administering oxygen.
3. Monitoring oxygen saturation.
4. Carefully repositioning the client every 2 hours.
4. Carefully repositioning the client every 2 hours.
Rationale:
The intervention appropriate for the client experiencing ineffective tissue perfusion is to carefully reposition client every 2 hours because position changes facilitate circulation and tissue perfusion. The other interventions would be appropriate if the client were experiencing impaired gas exchange.
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The nurse notes that a client who is in renal failure is taking a drug that is excreted by the kidneys. The nurse is concerned about administering this drug because:
1. the drug might not work on the client. 2. the drug could accumulate to toxic levels in the blood. 3. the drug will be excreted in the stool. 4. the drug will be excreted by the liver.
The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fracture tibia. What should the nurse inform the client prior to the cast being removed?
A) The leg will look as it did prior to the cast being applied. B) The leg will look moist and will have small bumps that will go away in a few days. C) The skin may be covered with a yellowish crust that will shed in a few days. D) The leg strength is enforced by the wearing of the cast.
Which principle best applies to care of a patient diagnosed with conversion disorder?
a. Structure care to provide time for rituals. b. Facilitate progressive review of the trauma. c. Give attention to the patient, not the symptom. d. Permit dependence while the symptoms are acute.
The nurse performing a postpartum assessment on a client elicits the Homan's sign. For what condition is the nurse assessing?
A) Thrombophlebitis B) Urinary distention C) Soft, boggy uterus D) Hematoma