Which of the following interventions would a nurse include in the plan of care for an incontinent patient with a stage II sacral pressure ulcer with no activity restrictions? Select all that apply
1. Repositioning the patient every 2 hours
2. Getting the patient up in a chair for meals and prn
3. Assessing the patient's incontinence pads every shift
4. Massaging the area around the decubitus bid
5. Elevating the patient's heels while he or she is in bed
ANS: 1, 2, 5
You might also like to view...
A 22-year-old female with a history of intermittent flank pain, repeated UTIs, and hematuria has been diagnosed with autosomal dominant polycystic kidney disease (ADPKD)
Which of the following phenomena has most likely contributed to the development of this diagnosis? A) UTIs coupled with an impaired immune response have caused her ADPKD. B) She has inherited a tendency for epithelial cells in her tubules to proliferate inappropriately. C) Severe hypertension and portal hypertension are likely precursors. D) She has inherited undersized kidneys that are prone to calculi formation.
A nurse is preparing to measure a client's pulmonary artery wedge pressure (PAWP). In what position should the nurse place the client for the most accurate results?
A. Supine, with the head elevated to 45 degrees B. Prone, with the head elevated to 30 degrees C. Trendelenburg position D. Lithotomy position
A new nurse is listing the interventions he should employ when caring for a client on thrombolytic therapy. Which nursing intervention is inappropriate for the client during thrombolytic therapy?
a. Monitor vital signs and reporting changes. b. Check for active bleeding for 24 hours after therapy. c. Inform the client that aspirin and NSAIDs may be taken for discomfort. d. Monitor electrocardiogram strips for cardiac dysrhythmias.
After cytologic examination a patient is diagnosed with a tumor that is staged as TIS, N1a, M0. What does this staging classification indicate to the nurse about the patient's tumor? Select all that apply.
A. N1a means one lymph node is involved. B. M0 means that it has metastasized. C. N1a means that no lymph nodes are involved. D. M0 means that it has not metastasized. E. TIS means the tumor is in situ.