During preparation for surgery, the nurse applies which of the following to facilitate venous blood return?
1. Sequential compression devices
2. Histamine-receptor antihistamines
3. Anticholinergics
4. Cleansing enema
1
Rationale: SCDs are used to promote venous return from the legs; they inflate and deflate plastic sleeves wrapped around the legs to promote venous flow
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The nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks, "What is the most important part of a pain assessment?" Which response by the nurse educator is the most appropriate?
1. "Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment." 2. "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important." 3. "Vital signs are not reliable indicators of acute pain, because only some clients are able to elicit a change in blood pressure or pulse rate." 4. "The response to pain is unique and based on numerous factors, which need to be assessed."
A nurse assesses an elderly patient brought to the emergency department by a grandchild who found the patient wandering in the front yard saying, "I can't find my way home." The patient is confused and unable to answer questions
Select the nurse's next action. a. Document the confusion. Obtain other assessment data from the grandchild. b. Record the patient's answers to questions on the hospital assessment form. c. Ask a more experienced nurse to perform the assessment interview. d. Call for a mental health advocate to support the patient's rights.
A client is receiving warfarin (Coumadin) daily following total hip replacement surgery. Which laboratory value requires intervention by the nurse?
a. Potassium (K+), 4.2 mEq/L b. International normalized ratio (INR), 5.1 c. Prothrombin time (PT), 13.4 seconds d. Hemoglobin (Hg), 16 g/dL
Christy has exercise-induced and mild persistent asthma and is prescribed two puffs of albuterol 15 minutes before exercise and as needed for wheezing. One puff per day of beclomethasone (QVAR) is also prescribed. Teaching regarding her inhalers includes:
1. Use one to two puffs of albuterol per day to prevent an attack with no more than eight puffs per day 2. Beclomethasone needs to be used every day to treat her asthma 3. Report any systemic side effects she is experiencing, such as weight gain 4. Use the albuterol metered-dose inhaler (MDI) immediately after her corticosteroid MDI to facilitate bronchodilation