The nurse does which of the following when performing oral care on the unconscious client to reduce the risk of aspiration pneumonia?
1. Use commercial mouthwash.
2. Apply mineral oil to the mucous membranes of the mouth.
3. Perform oral hygiene with normal saline.
4. Perform oral hygiene with hydrogen peroxide.
3
Rationale: Normal saline is isotonic, and would be less likely to cause pneumonia if a small amount were aspirated. Turning the client onto his side is also important to reduce the risk of aspiration.
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A 56-year-old male client with a recent diagnosis of erectile dysfunction has been prescribed sildenafil citrate (Viagra). In conducting client education, which of the following teaching points should the nurse provide to this client?
A) "It will likely take 2 to 3 weeks before you begin to see a difference in your erectile response." B) "Make sure that you don't take Viagra more than once each day." C) "You will likely get an erection around 30 minutes after you take Viagra and it will subside after a few hours." D) "If your erection lasts more than 24 hours, seek medical attention."
Patients with postpolio syndrome will have
A. tremors and spasticity. B. heat intolerance. C. mask-like expression. D. cold intolerance.
The health care provider informs you that Ms. P needs diagnostic testing to confirm an ectopic pregnancy. Which task should be delegated to the licensed practical nurse (LPN)/licensed vocational nurse (LVN)?
A. Assisting the provider to perform a pelvic examination. B. Obtaining a blood sample to test for luteinizing hormone. C. Premedicating before the procedure with a mild analgesic. D. Explaining the purpose and procedure of an ultrasound.
A nursing student asks her nursing instructor to describe the primary purpose of evaluation. Which of the following statements made by the nursing instructor is most accurate?
a. "During evaluation, you determine whether all nursing interventions were completed." b. "During evaluation, you determine when to downsize staffing on nursing units." c. "Nurses use evaluation to determine the effectiveness of nursing care." d. "Evaluation eliminates unnecessary paperwork and care planning."