When measuring a patient's weight, the nurse is aware of which of these guidelines?
a. The patient is always weighed wearing only his or her undergarments.
b. The type of scale does not matter, as long as the weights are similar from day to day.
c. The patient may leave on his or her jacket and shoes as long as these are documented next to the weight.
d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
ANS: D
A standardized balance scale is used to measure weight. The patient should remove his or her shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time.
You might also like to view...
When assessing superficial pain, touch, vibration, and position perceptions, you are testing:
a. cerebellar function. b. emotional status. c. sensory function. d. tendon reflexes.
As a part of preoperative teaching, the nurse is instructing the client on the use of a volume-oriented incentive spirometer. Which instruction should be included in this teaching? (Select all that apply.)
1. Blow out into the canister until the enclosed cylinder rises. 2. Close your lips tightly around the mouthpiece. 3. Inhale sharply to elevate the enclosed cylinder. 4. Use a nose clip to occlude nasal passages if necessary. 5. Cough after using the device. 6. Tilt the device slightly toward yourself while using.
The nurse is caring for a patient who is of American Indian descent. Which rituals and practices should the nurse assess as being used by this patient? (Select all that apply.)
a. Acupuncture b. The sweat lodge c. Herbal remedies d. Spinal manipulation e. The medicine wheel
MC A urinary diversion was done on a client with cancer of the bladder. You are assigned to apply the pouch. Which of the following actions do you complete?
A. Trace size of stoma on wafer. B. Cut opening 1 inch larger than stoma. C. Apply protective barrier to skin around stoma. D. Tape pouch securely to skin.