The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis?
1. Leg exercises
2. Coughing every 2 hours
3. Ambulating every 2 hours
4. Oxygen by mask
Correct Answer: 1
Rationale 1: Leg exercises may be implemented in the PACU to help prevent thrombophlebitis.
Rationale 2: Coughing every 2 hours does not prevent thrombophlebitis.
Rationale 3: Ambulation is not done in the postanesthesia care unit.
Rationale 4: Oxygen does not prevent thrombophlebitis.
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While trying to inform a young school-age client about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy
Which response by the nurse is the most appropriate in this situation? 1. "Please stop talking about your puppy. I need to tell you about your CT scan." 2. Ignore the child's responses and continue discussing the procedure. 3. "I'll come back when you are ready to talk with me more about your CT scan." 4. "You must be so excited to have a new puppy! They are so much fun. Now, let me tell you again about going downstairs in a wheelchair to a special room."
Which statement from the parent of a child diagnosed with attention deficit/hyperactivity disorder (ADHD) indicates the need for further education by the nurse?
1. "I will develop a reward system for desired behaviors." 2. "I will take my child to the physician every 3 months for a weight and height check." 3. "I will let him do his homework while he is watching his favorite television show." 4. "I will stick to the same routine each day after school."
The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses. The nurse would use the diagnosis of Impaired physical mobility for a patient who is
a. Not completely immobile. b. Completely immobile. c. At risk for multisystem problems. d. At risk for single-system involvement.
The nurse uses this type of assessment and organizes client data to determine if a client's current health patterns are working or not working:
a. body systems model c. hierarchy of needs b. functional health patterns d. human response patterns