The nurse is about to provide oral hygiene to an unconscious patient. To do so, she places the patient in which position?
a. Fowler's
b. Semi-Fowler's
c. Sims'
d. Supine
C
Unless contraindicated (e.g., head injury, neck trauma), lower the side rail and position the patient on the side (Sims' position) with the head turned well toward the dependent side and the head of the bed lowered. Raise the side rail. This allows secretions to drain from the mouth instead of collecting in the back of the pharynx and prevents aspiration. This position allows secretions to drain toward the lungs as a result of gravity.
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A nursing student informs you that the examination revealed ecchymoses on the face, breasts, and buttocks of a 14-year-old patient. Your best response is to inform the student that these findings are most likely related to which of the following?
a. liver dysfunction c. trauma from physical abuse b. heparin or Coumadin use d. familial blood condition
The nurse assesses that smoking, drinking alcohol, and exercising compulsively, which may occur as responses to a stressful situation, are which of the following types of responses?
1. External 2. Withdrawal 3. Denial 4. Internal
To measure jugular venous pressure, the patient should be placed in which position?
A) Supine B) High Fowler's C) Semi-Fowler's D) Prone
Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping?
a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.