Nursing interventions to reduce the risk of thromboembolism include which of the following activities? Choose all that apply
1) Keep the patient's hips and knees flexed while the patient is in bed.
2) Apply compression devices (e.g., sequential compression devices).
3) Turn the patient frequently or encourage frequent position changes.
4) Promote adequate hydration by encouraging oral intake.
ANS: 2, 3, 4
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The most appropriate nursing diagnosis for a patient who has difficulty maintaining a patent airway due to hemorrhage in the oral cavity would be:
A) Ineffective airway clearance B) Impaired swallowing C) Risk for trauma D) Ineffective individual coping
A patient reports hearing noises when alone in a quiet room. What action should the nurse take?
1. make sure the patient is referred to a psychiatrist 2. document that the patient has a mental illness 3. ask if the patient experiences any visual disturbances 4. explain to the patient that this is not unusual
To create a new nutritional plan of care for a patient, the nurse needs to do which of the follow-ing? (Select all that apply.)
a. Utilize the characteristics of a normal nu-tritional status. b. Evaluate previous patient responses to nursing interventions. c. Exclude established expected outcomes to evaluate patient responses. d. Design innovative interventions to meet the patient's needs. e. Follow through with evaluation and counseling.
Before completing a blood pressure on an adult, which should the nurse do next after introducing self?
A. Provide privacy. B. Perform handwashing. C. Identify the client with two identifiers. D. Explain what he or she will be doing with the client.