The nurse is supervising an unlicensed assistive personnel (UAP)in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which action by the UAP while repositioning the client would cause the nurse to intervene?
A. Keeping the head of the bed flat
B. Placing pillows beneath the full length of the legs
C. Using a log-rolling technique for repositioning
D. Having the client assist by using the overhead trapeze
Ans: D. Having the client assist by using the overhead trapeze
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A patient in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction
The patient shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well to her diagnosis and surgery. What nursing intervention is most appropriate to support this patient's coping? A) Encourage the patient's spouse or partner to be supportive while she recovers. B) Encourage the patient to proceed with the next phase of treatment. C) Recommend that the patient remain optimistic for the sake of her children. D) Arrange a referral to a community-based support program.
A patient who came to the clinic after finding a mass in her breast is scheduled for a diagnostic breast biopsy. What is a priority nursing action?
A) Acknowledge the fear the patient is experiencing. B) Refer her to a breast cancer recovery group. C) Set up a consultation with a breast cancer survivor. D) Instruct the patient on prosthetic devices.
The nurse is preparing to feed a 10-month-old child diagnosed with failure to thrive (FTT). Which actions should the nurse plan to implement? (Select all that apply.)
a. Be persistent. b. Introduce new foods slowly. c. Provide a stimulating atmosphere. d. Maintain a calm, even temperament. e. Feed the infant only when signs of hunger are exhibited.
When caring for a client with sepsis, the nurse recognizes that which of the following indicates a progression to severe sepsis? Select all that apply
1. Client requires intubation and mechanical ventilation for respiratory failure 2. Blood pressure of 80/42 after 4 liters of fluid have been given 3. Hematuria, epistaxis, and oozing from central venous catheter site 4. WBC count of 4000 cells/cubic millimeter 5. Urine output of 40 to 60 milliliters per hour