A client receiving an enema should be placed on the right side in the Sims’ position. A client with a below-the-knee amputation should be positioned with the affected limb elevated at a 45-degree angle. Clients with pulmonary edema should be positioned upright with the legs dangling over the side of the bed. Clients with a…
The nurse is caring for a client who has a nasogastric tube for medication administration and tube feedings. How should the nurse care for the tube during her shift? Select all that apply.
flush tube every 4 hours with hot water to maintain patency allow the feeding and tubing to hang until empty, up to 48 hours maintain the head of bed in a high-Fowler’s position during feedings check residuals and replace them unless the amount is greater than 300 mL check under the adhesive tape on the…
The nurse is discharging a client who was prescribed prednisone. The nurse tells the client that one of the side effects may be impaired sleep. The client says, “I already have a hard time sleeping. What can I do to help with that?” Which recommendations should the nurse make? Select all that apply.
avoid alcohol late in the evening keep the bedroom dark and quiet maintain the same consistent sleep schedule eat a large, heavy meal at dinner to help promote sleep read or do another quiet, noncomputer activity before bed do a vigorous exercise routine after work to help him become tired
The nurse is preparing to discharge a client who was treated for tuberculosis. Which guidelines for home management should the nurse include in his discharge teaching? Select all that apply.
The client may resume his normal activities. The family should maintain respiratory isolation at home. The medication regimen should be followed diligently as prescribed. The client may return to work when three sputum cultures are negative. The nurse should educate the client about the medication and possible side effects and their management.
The nurse is caring for a client whose lab results show triglycerides of 380 and cholesterol level of 240. Which foods would the nurse educate the client about including in his diet when he is discharged? Select all that apply.
wheat toast with sugar-free jelly grilled salmon seasoned with herbs an egg-white omelet with vegetables natural honey from a local farmer’s market plain grilled steak prepared with pepper only
The nurse is preparing to receive an 18-month-old client from surgery who had repair of a congenital hip deformity. What type of traction does the nurse anticipate setting up for the client?
_____________________
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other suspicious and untrusting of others, argumentative, controlling…
The nurse is precepting a new nurse in the psychiatric unit. The nurse is discussing interventions for schizophrenia. Which statement by the student nurse indicates an understanding of management of schizophrenia? Select all that apply.
“I should be warm and friendly to put the client at ease.” “I can reassure the client that he is in a safe environment.” “Puzzles or word games are good activities to engage in.” “I can help the client use art or writing to express his feelings.” “I won’t tell the client when I’m leaving…
The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia?
residual schizophrenia paranoid schizophrenia catatonic schizophrenia disorganized schizophrenia undifferentiated schizophrenia
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
administers medications as ordered uses gentle touch to reassure the client tells the client that others see or hear what he does distracts the client by placing him in the dayroom with others asks the client if he hears voices telling him to harm himself or others goes along with what the client says to…