A student nurse is bathing a patient with right lower lobe pneumonia. The student nurse is concerned with maintaining the patient's dignity, warmth, and safety. Which of the actions will prevent the spread of microorganisms?
a. Use superfatted soap.
b. Wash from the cleanest to the contaminated body part.
c. Use gloves when washing the patient's face.
d. Moving the call light out of reach of the patient to prevent it from becoming wet.
B
Always perform hygiene measures moving from the cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities. Use of superfatted soap will prevent skin breakdown. Use of gloves when washing the patient's face decreases the patient's dignity. For safety, the patient should have access to the call light at all times.
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A nurse is to obtain a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter connected to a closed drainage system. The specimen should be collected from:
a. the collection bag c. the collecting tubing b. the catheter d. the tubing and the collection bag
Your patient has a positive bulge sign and a palpable click upon ballottement, which most likely indicate
a. a small effusion of his knee. c. a large effusion of his knee. b. torn cartilage within the knee joint. d. torn ligaments of the knee.
In making out the assignment for the evening shift, the LPN charge nurse is careful to assign IV rounds to be performed:
1. every 15 minutes. 2. every 30 minutes. 3. every 60 minutes. 4. twice per shift.
Which information about a 76-year-old patient is most important for the admitting nurse to report to the patient's health care provider?
a. Triceps reflex response graded at 1/5 b. Unintended weight loss of 20 pounds c. 10 mm Hg orthostatic drop in systolic blood pressure d. Patient complaint of chronic difficulty in falling asleep