Which of the following interventions will assist the acute care patient in the PICU with the prevention of skin breakdown?
1. Using water-based skin moisturizers for dry skin
2. Keeping the child well oxygenated and well nourished
3. Changing positions at least every two hours
4. All of the above
4
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1. The intervention will help prevent skin breakdown.
2. Oxygenation and nutrition are important factors in prevention of skin breakdown.
3. Changing positions helps prevent the pressure points from developing breakdown.
4. The interventions listed all help to prevent skin breakdown of the hospitalized child.
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You are admitting a 22-year-old client who is experiencing palpitations, light-headedness, and fatigue. She has congested lungs and frothy sputum, consistent with heart failure. Her health care provider has diagnosed her with cardiomyopathy
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Acknowledging the relationship between pain and culture, the nurse should
A) treat all members of an ethnic group the same for pain management. B) expect stoicism from most individuals from westernized cultures. C) ask the client and family about practices used to manage pain. D) provide routine pain medication regardless of pain expression.
The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache
After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse a. Notifies the health care provider to obtain a verbal order. b. Directs the nursing assistant to give the Tylenol. c. Administers the Tylenol. d. Performs a pain assessment only after administering the Tylenol.