For cast removal, the nurse correctly instructs the client that:
A. Discomfort will be felt from the cast saw
B. An enzyme wash may be applied to intact skin
C. The skin will be scrubbed very well after the removal
D. Aggressive range-of-motion exercises will be performed after removal
B
B. If skin is intact, gently apply cold water enzyme wash to skin; let stay on skin 15 to 20 minutes. Helps dissolve or emulsify dead cells and fatty deposits on tissues. Prevents injury to delicate tissue.
A. Cast saw vibrates cast loose; client will feel heat and vibration.
C. Do not scrub skin, because this may traumatize delicate tissue and lead to skin breakdown. It may take several days before all residue is removed from skin.
D. Obtain physician's order to gently put joints through active and passive ROJM. Clarify level of activity allowed. Joints and muscles will be stiff and weak. Activity is resumed slowly to avoid reinjury.
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While caring for a woman who underwent a primary cesarean section for a breech presentation, she states this baby seems to have so much more mucus than her first baby. Concerned, she asks why this has happened. How should the nurse respond?
A) "Babies born by cesarean section have more respiratory complications because they do not have the benefit of having the mucus in their lungs removed by the pressure experienced in the birth canal." B) "There is no scientific reason for this occurrence." C) "All babies are different so it is unwise to make comparisons." D) "The pain medication given during the surgery may have contributed to the mucus build up."
The nurse is preparing to document a client's position that is laying on their back facing the ceiling. Which terminology should the nurse use in the documentation?
A. Lateral. B. Anterior. C. Prone. D. Supine.
During an assessment, the nurse determines a client is demonstrating symptoms of a psychosis. Which clinical manifestations did the nurse find during the assessment of this client?
Standard Text: Select all that apply. 1. The client says, "The servants need to be disciplined." 2. The client says, "The voice told me to cut myself." 3. The client laughs when asked about the health of a family member hospitalized for cancer treatment. 4. The client asks to close the room door so "that man can't get to me." 5. The client says, "I have not been able to get any sleep for months."
Correct the medical notation of the following order
? Heparin 1,000 u SC q.d.