Which nursing intervention would the nurse implement to decrease the risk of a surgical client developing thrombophlebitis?
1. Administer an anticoagulant
2. Cough every 2 hours
3. Intake and output every 2 hours
4. Early ambulation
Correct Answer: 4
Rationale 1: Anticoagulant therapy must be prescribed by a physician.
Rationale 2: Coughing every 2 hours will reduce the client's risk of developing pneumonia or atelectasis.
Rationale 3: Measuring intake and output every 2 hours assesses the client's renal function.
Rationale 4: Early ambulation, leg exercises, antiemboli stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis.
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1. Nondisjunction has not occurred. 2. The fetus's organ systems are involved. 3. There is trisomy in the placenta. 4. There is trisomy in at least one fetal tissue.
The nurse is assessing the ears of a patient who is African American. Which assessment finding should the nurse identify as abnormal?
1. During the Rinne test, the patient hears the sound by air conduction for an equal amount of time as by bone conduction. 2. The patient is able to hear whispers from 18 inches away. 3. The patient's cerumen is dark gray. 4. The patient's tympanic membrane is pearly gray.
A 21-year-old client informs the nurse that he is not sleeping. The nurse learns that the client's girlfriend was killed in a car accident 1 month ago. Which statement would be of most concern to the nurse?
a. "I am moving on and plan to start dating again." b. "It's my fault. I shouldn't have let her go out that night." c. "I wish I died in the car accident instead of her." d. "I cannot sleep because I keep reliving the car accident."
The nurse commits an error while caring for a patient who receives Medicare benefits. The error results in a complication that is on the Centers for Medicare and Medicaid Services' "never list." What is the implication of this error?
1. The nurse will be investigated by the state's Board of Nursing. 2. The nurse's employment will be terminated. 3. Medicare will not pay for the cost of the complication. 4. The patient will have to share the cost of the care for the complication with Medicare.