Basic Care and Comfort

Which activity should the nurse complete after the client's death?

Place body in normal anatomic position (prevents pooling of blood) Replace soiled dressings Tubes should be handled according to the facility's policies Mortician washes body (or family)

Left-sided CVA. Pt is right-handed and aphasic. How to communicate?

Provide flip cards with pictures that have words, phrases, and activities (Can't write b/c right hand is affected)

Urolithiasis

Kidney stones Record I/Os Strain urine Monitor BUN and creatinine Increase fluids to 3-4 L/day Decrease sodium intake

Why vitamin C is good for wound healing

Promotes protein synthesis

A client in the second stage of Alzheimer's disease appears to be in pain. Which question by the nurse would best elicit information about the pain?

"Do you hurt?" (pause) "Do you hurt?" Explanation: When speaking to a client with Alzheimer's disease, the nurse should use close-ended questions (those that the client can answer with "yes" or "no") whenever possible, and avoid questions that require the client to make choices. Also, repeating the question aids comprehension.

Suggests that the child is at risk for iron-deficiency anemia?

"He drinks over four glasses of milk per day." Explanation: Milk is a poor source of iron. Toddlers should have between two and three servings of milk per day. Iron-deficiency anemia can be caused when excessive milk intake of more than 32 oz (1 liter)/day intake displaces iron-rich food in the diet. While 6 oz (300 mL) is the recommended daily limit for apple juice, it does contain more iron than milk. Food preferences vary among children. It is acceptable for the child to refuse foods as long as the diet is balanced and contains adequate calories.

After arriving to view a deceased client, the family asks why intravenous lines and tubes are still inserted into the body. Which response should the nurse make to the family?

"The client had an advance directive for an autopsy and all tubes need to remain in place." Explanation: If an autopsy is to be performed, any tubes that were in place while the client was alive should not be removed. The intravenous lines and tubes are not in place because the mortician requested them to be present. All tubes and intravenous lines would be removed before the family visits unless an autopsy is being planned. A health care provider's order is not required to remove the tubes and intravenous lines of a deceased client.

Preop teaching plan for colostomy

-Demonstrate turning, coughing, deep breathing, splinting, and leg ROM exercises, and provide rationales for each procedure. -Arrange for an enterostomal therapist (ET) to speak with the client about colostomy care. -Explain the need for early postoperative ambulation. -Encourage the client to express feelings about changes in body image.

Cellulitis with pain and edema

Alternate warm and cold compresses (inc wound healing and improve pain) Hot/cold to improve edema Allows for local vasodilation for WBCs to come in and toxic waste to go out NO COMPRESSION DRESSINGS = Impair circulation, delay healing

Sterile collection of urine from indwelling cathether

Apply gloves before cleansing port Don't take sample from drainage bag Don't disconnect drainage tubing

Ensures max functioning of upper extremities post-mastectomy

Arm exercises

Nutrition for elderly with HTN

Avoid grapefruit (citrus fruits - talk to HCP) Frozen veggies over canned Inc monounsaturated fats Dec polysaturated and transfats

Radiation therapy - coping with fatigue

Balance activity and rest

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

Acute glomerulonephritis

Characterized by hematuria, proteinuria, and RBCs in the urine from glomeruli not working. Edema, HTN, fluid retention Most common cause in kids is strep BP levels rise rapidly and should be monitored q4h Limit fluids Bed rest

Introducing solid foods to a baby

Ready when reaching for foods on table, putting toys in mouth, good hand-mouth coordiation, sits supported, & good head control (~4-6 mo) Introduce veggies before fruits (bland to sweet) 1 new food introduced per week (to monitor for allergies/intolerance) Limit juice (promotes malabsorption)

Mom wants to pre-pregnancy weight but is breastfeeding

Eat a well-balanced diet with adequate calories so breast milk has sufficient nutrients. Don't restrict diet too much

Clients with gout should avoid:

Foods that are high in purines, such as liver, cod, and sardines, as well as anchovies, kidneys, sweetbreads, lentils, and alcoholic beverages — especially beer and wine. Green, leafy vegetables, strawberries, and eggs aren't high in purines and are acceptable foods to eat.

Below-the-knee amputation

Foot of bed elevated for first 24 hoursn (or use pillows) After 24 hrs, position flat on bed to prevent contractures PT & ROM begins immediately (post-op day 1) Position prone daily to provide for hip extension

Post-op intracranial aneurysm interventions

Give stool softener to prevent straining (inc ICP) Bed rest for first few days (no early ambulation!) DVT prophylaxis Regular diet Triple H treatment: Hypervolemia, HTN, hemodilution (fluids)

Fluids to help with rehydration for child with fluid volume deficit

Half-strength juice Not full-strength (high osmolarity = diarrhea, water loss) Need sugar for electrolytes but not simple sugar

Diet for pancreatitis

High carb low fat diet Avoid fatty foods, caffeine, and gas-forming foods, and large meals An increased sodium or fluid intake is not necessary because chronic pancreatitis is not associated with hyponatremia or fluid loss.

Different size legs for antiembolism stockings

If a client's thighs do not measure the same, the nurse would order two different sizes of stockings to create an appropriate fitting pair. Measure the client's legs and select the appropriate stocking based on the size of the client's thighs. Stockings must be sized correctly in order to apply the correct amount of pressure on the leg. If a stocking is too small, it may compress the vessels and impair circulation. If the stocking is too large, it may not improve venous return effectively.

Managing cancer pain

Individualize the plan of care for managing pain Best managed with a combination of medications Commonly undertreated because of fear of addiction Best treated with regularly scheduled doses

Sleep deprived EEG

Records electrical activity of brain after having less sleep Mostly awake for the previous day (max sleep 4 hours) Avoid caffeine - interferes with results Usually lasts 2 hrs (1 hr sleep, 1 hr awake) Eat before test to avoid dips in BS Take meds as usual

Diet for diabetes mellitus

Should contain appropriate amounts of proteins, fats, carbs, plus adequate minerals and vitamins. Limit carbohydrate intake Lifelong insulin therapy

Inteventions for opioid withdrawal for an infant

Swaddle the infant in a blanket. Use slow vertical rocking. Dim lighting around the crib. Plan care around infant cues.

Measures to relieve hemorrhoid discomfort

Lie in the Sims position to aid venous return to the rectal area Stool softeners can decrease pain but discuss with PCP first Analgesic sprays and witch hazel pads Drink lots of water and eating roughage

Catatonic schizophrenia

Loss of motor movement and speech Priority is adequate nutrition -- assist with feeding Hold same position for hours Don't eat, drink, go to bathroom Hyperactive repetitive movements w/o purpose

A nurse must apply an elastic bandage to a client's ankle and calf. The nurse should apply the bandage beginning at the client's:

Lower foot An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot.

A child is prescribed amoxicillin for otitis media. What should the nurse recommend the mother do when the child develops diarrhea?

Offer yogurt several times a day. Withholding food and fluids for 2 hours is only for when a child vomits.

Vitamins necessary for wound healing

Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin for wound healing. Protein for improving skin integrity. Vitamin D and calcium are necessary for bone healing.

Teaching plan for peripheral arterial disease (PAD) foot care

Wear well-fitting slippers when ambulating. Pat dry the feet after cleaning with a neutral soap. Examine the feet routinely for signs of inflammation or infection. Assure that toenails are trimmed straight across.

Good source of protein for a child

Yogurt Dry beans Peanut butter

Fall risk factors

above age 60 previous fall bowel/bladder incontinence or urinary freuqency sedatives, diuretics, ntihypertensives, CNS drugs unsteady gait weakness, limited mobility hypotension visual/auditory impairments dementia tubes med equipment scds restraints

The nurse assesses an infant's urine output and bowel movements. What guideline does the nurse use when determining the appropriate number of wet diapers and stools for an infant at 24 hours of age?

at least six wet diapers and one to three black to dark green stools Explanation: Newborn elimination patterns are highly individualized. Usually the urine is light amber in color. Soaking 6-12 wet diapers a day indicates adequate hydration. Meconium is passed for the first 48 hours. These stools appear thick, tarry, sticky, and dark green. Transitional stools appear by day 3. The coloration and consistency of these stools depend upon if the neonate is breastfed or bottle-fed. Breastfed infants usually pass mustard-colored stool with a seedy consistency. Formula-fed newborns pass yellow to brown soft stools with a pasty consistency.

For a bottle-fed neonate, the first feeding usually consists of

iron-fortified formula

To determine whether the client has an adequate intake of vitamin A, the nurse should assess the client's diet for consumption of:

milk. Explanation: Common food sources of vitamin A include dairy products, liver, egg yolks, fruits, and vegetables. Fish and meat are good sources of protein. Cereals, especially whole grains, are good sources of niacin, vitamin B1, and vitamin B6.

Which night clothes would the nurse recommend for an infant with atopic dermatitis?

one-piece cotton pajamas with long sleeves The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate.

When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate?

prone with hips in abduction (to decrease tension on sac)

Older adult who has hip pain related to rheumatoid arthritis. Which type of chair to sit in?

straight-back chair with elevated seat Maintain proper posture and body alignment to support joints and decrease pain and stiffness. Elevated seats avoid excessive hip flexion

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

weighing the client daily at the same time each day