The nurse is caring for a patient who has a newly casted, fractured wrist. Data collection reveals slightly puffy fingers with good capillary refill. What should the nurse do now to prevent complications?
a. Notify the RN.
b. Apply heat to the cast.
c. Elevate the cast on pillows.
d. Remove the pillow under the cast.
ANS: C
A casted limb is elevated for 24 to 48 hours, and ice can be applied above and below the cast to reduce swelling. A. The RN does not need to be notified. B. Heat should not be applied at this time. D. The pillow should not be removed from under the cast.
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When the nurse intentionally creates and implements changes to assist the client, the nurse is acting in which role?
a. leader c. change agent b. instigator d. stress manager
The emergency department nurse is admitting a client who has been sexually assaulted. The nurse is explaining how the physical evidence will be collected. Which statement by the client indicates that teaching has been effective?
1. "All the evidence will be kept in a locked cupboard until the police arrive." 2. "You collect urine samples to make sure the rapist did not get me pregnant." 3. "The evidence you collect might be able to identify the rapist." 4. "Blood samples are taken to help identify whether the rapist had HIV."
A 16-year-old client says, "My dad thinks I'm evil, but we get into fights because I let things build up. He never has any time for me because he's always glued to the TV. He doesn't even look at me when he talks." Which statement by the nurse encourages the client to use assertive behavior with his father?
A. "So you're saying that you let your feelings build up and then you just explode?" B. "Have you tried standing in front of the television when your dad is watching it?" C. "What makes you feel that you have the right to fly off the handle just because you feel ignored?" D. "Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"
A patient is placed in Buck's traction after a hip fracture. What should be included in this patient's plan of care?
A. Providing pin site care every shift as prescribed B. Turning the patient to the unaffected side every 2 hours C. Having another person hold the weights when pulling the patient up in bed D. Placing an abduction pillow between the legs for alignment