A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority?
a. Assess for contraindications to fibrinolytics.
b. Ensure that informed consent is on the chart.
c. Perform a full neurologic assessment.
d. Review the client's medication lists.
ANS: B
For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.
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Which of the following statements is appropriate for a nurse to teach a patient regarding the use of crutches?
a. "The axillae should support all your body weight." b. "Your elbows should be straight when your hands are on the crutch handgrips." c. "The distance between the crutch pad and axillae should be three to four finger widths." d. "Your elbows should be flexed about 45 degrees when the handgrip position is correct."
A client with acute leukemia develops a neutrophil count of 450/mm3 . The nurse should (Select all that apply)
a. allow no plants or live flowers in the room. b. allow no visitors at this time. c. ensure strict adherence to hand-washing protocol. d. place the client on protective isolation. e. restrict the client's access to raw fruits and vegetables.
Which statement by the nurse is incorrect regarding herbal therapy?
1. Herbs cause no significant side effects. 2. Herbs can interact with prescription medication. 3. Natural does not always mean better or safe. 4. Not all natural substances are therapeutic.
In discussing guidelines for parents to use in monitoring television viewing, the nurse would include: (Select all that apply.)
a. Encouraging active outdoor recreation b. Limiting viewing to 4 hours per day c. Teaching critical viewing techniques of frequently watched shows d. Using television during meals for entertainment e. Letting the child choose a book from the library to read