A home health nurse looked at the day's assignment. Of the five clients listed below, which should the nurse visit first?
A. A married couple who live 10 blocks away and who are having problems with independent living since the husband developed a staph infection
B. A client with AIDS who is waiting for a hospice opening and is currently in an apartment seven blocks away
C. A new admit with unknown problems, who lives eight blocks away
D. A man with a draining chest abscess who is on IV antibiotics and lives 12 blocks away
ANS: B
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a. Palpate forcefully through the abdominal dressing. b. Gently palpate, applying the same technique used for vaginal deliveries. c. Place hands on both sides of the abdomen and press downward. d. Rely on assessment of lochial flow rather than palpating the fundus.
The nurse instructs a patient on the use of a metered-dose inhaler for asthma medications. To demonstrate understanding of the instructions, in which order should the patient self-administer this medication?
1. Rinse the mouth. 2. Exhale slowly and completely. 3. Shake the canister vigorously for 3 to 5 seconds. 4. Press and hold the canister down while inhaling deeply and slowly for 3 to 5 seconds. 5. Hold the breath for 10 seconds, release the pressure on the container, remove from the mouth, and exhale.
The client who was diagnosed with diabetes mellitus 1 year ago is hospitalized in diabetic ketoacidosis after a religious fast. The client tells the nurse, "I have fasted during this season every year since I became an adult
I am not going to stop now." The nurse is not knowledgeable about this particular religion. What is the best action for this nurse? A) Tell the client that it is different now because of the diabetes. B) Request a consult from a diabetes educator. C) Ask family members of the same religion to discuss fasting with the client. D) Do some research into the meaning of fasting in this religion.
The nurse caring for the woman in labor should understand that increased variability of the fetal heart rate may be caused by:
a. Narcotics. c. Methamphetamines. b. Barbiturates. d. Tranquilizers.