Ten minutes after the nursing assistant applies an Aquathermia pad to the client's extremity, the client states that the pad is not warm. Which should the nurse implement?
1. Tell the nursing assistant to secure pad to client tightly.
2. Instruct assistant to increase temperature control on pad.
3. Assess the client's condition and pad for proper function.
4. Discontinue treatment because the client is not tolerating it.
3
3. The nursing assistant lacks the clinical judgment and critical thinking skills of a nurse; thus, the nurse goes to the client's bedside, assesses the client and the extrem-ity, and ensures proper function of the Aquathermia device.
1 and 2. The most likely cause of the problem is that the pad is too loose around the tissue. Because the assistant lacks nursing judgment and critical thinking skills, the nurse assesses the pad and adjusts it accordingly to improve its proximity to the client's skin. The temperature is probably mandated by agency policy, prescription, or the manufacturer's setting.
4. The client states the pad does not feel warm, an unlikely response for a client who is intolerant to heat because the intolerant client is very sensitive to heat. Although the most likely cause of the client's statement is that pad is loosely applied, the nurse assesses the client for impaired sensation, peripheral vascular disease, and diabetes mellitus and palpates the pad to determine whether the pad is becoming warm.
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The student nurse studying bowel elimination learns that the following statements accurately describe the process of peristalsis. Select all that apply
A) The sympathetic nervous system stimulates movement. B) The autonomic nervous system innervates the muscles of the colon. C) Peristalsis occurs every 3 to 12 minutes. D) Mass peristaltic sweeps occur one to four times each 24-hour period in most people. E) Mass peristalsis often occurs after food has been ingested. F) One-third to one-half of ingested food waste is normally excreted in the stool within 48 hours.
A nurse in a medical care center notices that the sphygmomanometer used to measure the blood pressure of clients has a defective part and gives inaccurate readings. What initial action should the nurse take in this case?
A) Report and label the defective sphygmomanometer immediately. B) Replace the sphygmomanometer immediately. C) Try to repair the defect in the instrument. D) Order a new sphygmomanometer.
Hypertonic solutions are generally given to patients
A. with normal electrolyte levels. B. with low electrolyte levels. C. who are healthy, but having diagnostic tests. D. with dehydration.
In determining whether or not to request assistance in dealing with a person with a mental disorder, law enforcement officers should consider various factors impacting their decision. Which of the following is not one of these considerations?
a. The size and age of a person with mental illness b. Persons with a mental illness may, but not always, be unpredictable and irrational. c. A person with a mental illness may exhibit extraordinary strength. d. Backup may be needed for the safety of the officer, others, or the individual.