The nurse is caring for an adult client who has had surgery for cancer of the larynx. The client is restless, and is shaking the side rails. An appropriate nursing response would be:
1. "Why are you shaking the side rails?"
2. "You aren't scheduled for pain medication yet."
3. "May I get you a pencil and paper so you can tell me what is bothering you?"
4. "Can you point to where it hurts?"
3
Rationale: The use of probing questions with a client who cannot speak is not therapeutic.
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A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best?
a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.
The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?
a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.
The nurse explains that Bryant's traction is reserved for children who weigh less than _____ pounds
ANS:
A nurse caring for a 68-year-old patient diagnosed with mycoplasmal pneumonia observes that the patient has difficulty breathing due to copious tracheobronchial secretions. The patient should be encouraged to do which of the following?
A) Increase oral fluids unless contraindicated. B) Call the nurse for deep suctioning. C) Lie in a low-Fowler's position. D) Increase activity.