When assisting the client with using a bedpan, the nurse should:
A. Lower the client's head
B. Remove abduction pillows
C. Push the pan under the client's hips
D. Place the bedpan under warm water before use
D
D. Place bedpan under warm, running water for few seconds, then dry.
A. Raise client's head 30 to 60 degrees.
B. If client has had total hip replacement, the abduction pillow placed between the legs to prevent dislocation of the new joint must remain in place. Use a fracture pan.
C. Shoving the bedpan under the client increases the risk of friction injury to the underlying skin and tissues.
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The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure?
a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure. b. The best position to measure thigh pressure is the supine position with the knee slightly bent. c. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. d. The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels.
The nurse is caring for a client with a colostomy who has continuous liquid drainage with a fecal odor. Which term will the nurse use when documenting the type of colostomy for this client?
1. Ileostomy 2. Ascending colostomy 3. Transverse colostomy 4. Descending colostomy
The client has been receiving intravenous (IV) fluids for the last 6 hours and now is demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure more than 15 mm Hg higher than baseline
Which is the most likely nursing diagnosis for this client? A) Ineffective Peripheral Tissue Perfusion B) Ineffective Airway Clearance C) Excess Fluid Volume D) Impaired Tissue Integrity
The nurse is caring for an older adult client who has recently withdrawn from relationships, appears depressed, and appears reluctant to seek information from the nurse. The nurse suspects the client is experiencing hearing loss. The nurse recognizes that
a. the client will readily acknowledge that this is the problem if asked. b. the client may try to hide deficits and withdraw from relationships. c. decreased hearing ability is not related to conversational style. d. older adults, as a group, have better consonant discrimination.