MC Before using Rid and R&C which one of the following actions is considered the priority?
A. Place unopened tube of medication in warm water for 1 minute.
B. Comb hair using fine-tooth or lice/nit comb.
C. Determine if client has an allergy to ragweed or chrysanthemums.
D. Cleanse hair with usual shampoo.
C
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During an initial assessment, the nurse notes that the client reports being unable to walk more than a few steps without becoming short of breath. Which of these functional health patterns needs further investigation?
a. elimination c. coping/stress tolerance b. sleep/rest d. activity/exercise
The patient is admitted with generalized fatigue and a low hemoglobin and hematocrit (anemia). The patient denies vomiting and states that his last bowel movement earlier that day was normal in color and consistency
However, because GI blood loss can be a cause of anemia, the nurse should expect to: a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patient's next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.
When nurses are trying to determine whether patients and families need more information, they often ask, "Do you have any questions?" Which of the following statements best explains why this approach is flawed?
1. Patients and families will ask questions without being invited, and this approach is too direct. 2. This approach presumes that the family and patient are not on the healthcare team and may be condescending. 3. The question asks patients to share private information, which is a violation of HIPPA guidelines. 4. Patients and families often don't know enough about a situation to know what questions to ask.
A client with an ostomy is irrigating it with about 500 ml of warm tap water and is holding the irrigating container about 36 inches above the stoma. Which nursing diagnosis best fits this situ-ation?
a. Constipation b. Effective management of therapeutic regimen c. Enhanced individual coping d. Knowledge deficit