What is the priority nursing intervention for the client during the first 24 hours after a skin graft procedure?
A. Monitoring of vital signs for early detection of hemorrhage
B. Monitoring of graft site to assess "take" of the newly grafted skin
C. Repositioning the client every 2 hours to prevent pressure ulcer formation
D. Performing passive range-of-motion exercises on the extremity with the new graft to prevent contracture development
B
The most serious common complication in the early postoperative period after skin grafting is failure to engraft.
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A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which nursing intervention should receive the highest priority?
a. Conducting passive range-of-motion exercises b. Exposing the patient to auditory and visual stimuli c. Interacting with the patient as if he is responding d. Including the patient in a variety of milieu activities
All parents are entitled to a birthing environment in which breastfeeding is promoted and supported
The Baby Friendly Hospital Initiative endorsed by WHO and Unicef was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which is not one of the "Ten Steps to Successful Breastfeeding for Hospitals"? a. Give newborns no food or drink other than breast milk. b. Have a written breastfeeding policy that is communicated to all staff. c. Help mothers initiate breastfeeding within one half hour of birth. d. Give artificial teats or pacifiers as necessary.
A client with an esophagogastric tube suddenly experiences acute respiratory distress. Which is the nurse's first action?
a. Call the health care provider. b. Cut the balloon ports and remove the tube. c. Place the client upright and apply oxygen. d. Reduce the balloon pressure slightly.
The nurse is caring for a patient who is scheduled for a magnetic resonance imaging (MRI) scan. What explanation should be provided to the patient and family?
a. "A scan of the brain will be done after injection of a radioisotope." b. "An MRI uses electrodes placed on the scalp to measure activity of the brain." c. "An MRI measures muscle contraction after stimulation by tiny needle electrodes." d. "An MRI is a noninvasive test that uses magnetic energy to visualize internal parts."