The nurse removes an ice pack and notices that the area underneath the ice pack is blue. What action should the nurse take?
a. Reapply the ice pack.
b. Discontinue the use of ice packs.
c. Refill the ice pack to the top.
d. Reapply the ice pack without the wrapping.
B
Do not reapply the ice pack to red or bluish areas; continual use of the ice pack makes ischemia worse. When filling an ice pack, fill the bag two-thirds full with small ice chips. The bag is easier to mold over a body part when it is not full. However, in this case, do not reapply the ice pack.
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The nurse documents the first sign of a pressure ulcer that has not yet progressed to stage 1 when noting which of the following?
1. Nonblanchable reddened area on the coccyx 2. Mushy area on the buttocks that is cool to the touch 3. Wound covered with eschar 4. A blister on the buttocks
A patient is using a metered-dose inhaler containing albuterol for asthma. The medication label instructs the patient to administer "2 puffs every 4 hours as needed for coughing or wheezing."
that the medication is always effective. Which is not an appropriate nursing intervention for this patient? a. Asking the patient to demonstrate use of the inhaler b. Assessing the patient's exposure to tobacco smoke c. Auscultating lung sounds and obtaining vital signs d. Suggesting that the patient use one puff to reduce side effects
The nurse identifies the problem of imbalanced nutrition due to insufficient intake for a patient hospitalized for substance abuse. What intervention should the nurse identify as appropriate for this patient? Select all that apply.
A. Monitor the CBC and liver enzymes. B. Restrict fluid intake to 1500 mL per day. C. Provide high fat, high carbohydrate diet. D. Administer vitamins and diet supplements. E. Collaborate with the dietician.
The nurse is admitting the patient to the medical unit. The patient indicates that he has had several surgeries in the past and has been a diabetic for the last 15 years. He also states that he has allergies to sulfa and eggs
He claims that he had severe back pain earlier that morning, but the pain has finally gone since he received a "pain shot" in the Emergency Department. The nurse realizes that she must: a. Provide the patient with an allergy arm band and document his allergies b. Postpone routine admission procedures immediately c. Ask the patient if he wants a smoking room d. Have all family or friends leave the room