The nurse is completing the preoperative checklist on the night shift in preparation for the client's surgery, scheduled for 0800
Which tasks could the nurse complete at this time?
1. Documenting the time of last voiding
2. Checking the medical record for the history, physical, and signed informed consent
3. Administering preoperative medication
4. Removing the prosthesis
Correct Answer: 2
The nurse on night shift could check the medical record to ensure that a history and physical have been completed, and that the consent for surgery is signed. The nurse on day shift preparing to send the client to surgery would document time of last voiding and administration of preoperative medication. Many clients prefer to wait until just before going to surgery before removing dentures, contact lenses, and other prostheses.
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The nurse knows that one theory explaining the variation in response to stress among individuals is called:
a. stress appraisal. b. sense of coherence. c. allostasis. d. homeostasis.
After surgery to remove a cataract, which of the following should the nurse instruct the client?
1. "Be sure to follow the schedule for the prescribed eyedrop medication." 2. "Sleep on the right side to promote drainage." 3. "It is okay to rub the eye because the surgery was on the inside." 4. This is an outpatient procedure, and there are no instructions for the patient.
Ms. Cohen is a patient who is very weak. Although she is not extremely heavy, she is unable to help when turned or moved in bed. The nursing assistant caring for Ms. Cohen should
A. Turn Ms. Cohen only twice per shift, to decrease the chance of back injury. B. Ask the nurse to get an order for a turning sheet to use with Ms. Cohen. C. Ask a co-worker to help safely move and turn Ms. Cohen. D. Use a pillow to tilt Ms. Cohen rather than trying to turn her from side to side.
The nurse develops a nursing diagnosis of "fluid volume excess related to sodium retention secondary to steroid therapy as evidenced by weight gain of 12 pounds in 2 weeks and edema of lower extremities." Which goal is most appropriate?
a. Patient will verbalize importance of low-sodium diet. b. Ankle circumference will be measured for edema daily. c. Patient's fluid volume will decrease as evidenced by discontinuing steroids. d. Patient will have improved fluid balance as evidenced by weight returning to baseline.