The nurse intervenes for a patient with a perforation of the right eye by which of the following? (Place the interventions in the appropriate sequence.)
1. Cover the right eye with an eye shield.
2. Place the patient in a Fowler's position.
3. Clean around the right eye.
4. Cover the left eye with a light occlusive dressing.
5. Darken the room.
2, 3, 1, 4, 5
Fowler's position will decrease the risk of loss of more fluid from the eye. The area around the eye should be cleaned and the eye covered with an eye shield. The other eye should be covered to prevent sympathetic movement in the right eye. The room should be darkened to reduce pupillary response to light.
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The nurse charts signs of infected phlebitis as:
1. rupture of the cannula with a lump under the skin. 2. pale, cool skin with swelling at the puncture site. 3. firm, cool, raised, painful area at the puncture site; oozing; and purulent drainage 4. puncture site red, warm, with an oozing drainage.
Assessment of a woman's nutritional status includes a diet history, medication regimen, physical exam, and relevant laboratory tests. A maternity nurse making such an assessment should be aware that:
1. oral contraceptive use may interfere with the absorption of iron. 2. illnesses that created nutritional deficits such as PKU may require nutritional care before conception. 3. the woman's socioeconomic status and educational level are not relevant to her examination; they belong to the social worker, if to anybody. 4. the only nutrition-related laboratory testing needed by most pregnant women is for diabetes.
If no record was made for vital signs that were due at 12:00, it can be assumed that the:
a. vital signs were within reportable limits. b. vital signs were not assessed. c. individual required extra care. d. nurse had forgotten to record them.
Which of the following statements by the nurse reflect the use of therapeutic interaction techniques?
A) "You look upset. Would you like to talk about it?" B) "I'd like to know more about your children. Tell me about them." C) "I understand your husband passed away. I couldn't bear that." D) "You look very sad. How long have you been this way? Have you been taking care of yourself?"