Module 7: Basic Care and Comfort saunders
The nurse describes the bladder retraining program to Louis. Louis says, "I'm so worried about all of this. It's so embarrassing not to be able to control my urine. Do you think this will work? I've heard that diabetes causes these kinds of urinary problems. To top it off, I have this enlarged prostate!" Which therapeutic statement should the nurse make? "Diabetes mellitus has no effect on urination." "Don't worry. We'll have you back in shape in no time!" "Diabetes mellitus can cause alterations in urinary patterns because the condition affects the nerves that help the bladder function." "Having an enlarged prostate will make things difficult, but with hard work and compliance with the program, everything will work out fine."
"Diabetes mellitus can cause alterations in urinary patterns because the condition affects the nerves that help the bladder function." RATIONALE: Systemic diseases such as diabetes mellitus can affect renal and bladder function. The renal alterations result from injury to the glomeruli or renal tubule that interferes with the normal filtering, reabsorption, and secretory functions. Renal dysfunctions are first noted with microalbuminuria. The bladder dysfunction is affected by diabetic autonomic neuropathy. Therefore, stating diabetes-mellitus has no effect on urination is incorrect. Telling the client not to worry and that things will work out fine is incorrect because these are nontherapeutic responses that provide false reassurance.
A nurse is providing instruction to a client with a muscle sprain about the procedure for applying cold packs to the site of injury. Which of the following statements by the client indicate an understanding of the procedure? Select all that apply. "I'll place the cold pack on the site of injury and lie on the pack." "I'll place the cold pack directly on the skin at the site of the injury." "I'll leave the cold pack on until the ice melts and then replace it with another cold pack." "I'll cover the cold pack with a pillowcase and apply the pack to the injury site for no more than 30 minutes." "I should remove the cold pack right away if I notice any changes in sensation or if I experience discomfort after I apply it to the injury site."
"I'll cover the cold pack with a pillowcase and apply the pack to the injury site for no more than 30 minutes." "I should remove the cold pack right away if I notice any changes in sensation or if I experience discomfort after I apply it to the injury site." RATIONALE: To help prevent skin injury, the client is instructed not to lie on the cold pack. The cold pack is covered with a flannel cover, towel, or pillowcase and applied to the injury site for no longer than 30 minutes. The client is instructed to immediately remove the cold pack if changes in sensation or discomfort occur after its application. If the changes in sensation or discomfort are not relieved after removal of the cold pack, the health care provider should be notified.
Louis has had no episodes of urinary incontinence today and is preparing for discharge home. Which statement by Louis indicates that he understands his discharge teaching? "I won't need to continue the bladder retraining program." "You can tell that my bladder is back under control because I wasn't incontinent at all today." "I'll keep using parts of the bladder retraining program at home." "I will just try to do everything my doctor want me to."
"I'll keep using parts of the bladder retraining program at home." RATIONALE: The goal of a bladder retraining program is to restore a normal pattern of urination. Although the program may be started in the hospital or rehabilitation unit, it may need to be continued at home for some time. If Louis' bladder control has been totally regained, discontinuation of the bladder retraining program would be appropriate, but being continent today could just be a result of inadequate fluid intake. The nurse would encourage the client to continue the program at home. A doctor's prescription is not required.
Larry is scheduled for surgery and will be placed in skeletal traction. Which statement by the nurse to Larry in the preoperative period, specific to this surgery, is correct? "If you or your family have any questions, be sure to ask them." "You will have pins attached to the inside and outside of your leg." "You will sit on the edge of your bed and walk the night of surgery." "It may be cold in the operating room, but you can request warm blankets."
"You will have pins attached to the inside and outside of your leg." RATIONALE: Skeletal traction involves the application of pins to the bone, which are then used externally to provide traction. Although it is important to ensure that the client and family do not have questions, this is important for all surgeries, not just this one. The client in skeletal traction is not allowed out of bed. Although it may be cold in the operating room, this statement refers to all types of surgery and is not specific to skeletal surgery.
A client with hypertension is taking a prescribed dose of atenolol 50 mg daily by mouth. The client tells the clinic nurse that she would like to take an herbal substance called cat's claw, known to lower blood pressure. Which action should the nurse take? Telling the client that herbal substances are not safe and should never be used Advising the client to discuss the use of the herbal substance with her health care provider Teaching the client how to take her blood pressure so that she may monitor it closely Telling the client that if she takes the herbal substance, she will need to have her blood pressure checked frequently
Advising the client to discuss the use of the herbal substance with her health care provider RATIONALE: Although some herbal substances have beneficial effects, not all herbs are safe to use. Clients being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects because the combination may result in an adverse reaction. Therefore the nurse would tell the client to discuss the use of the herbal substance with the health care provider
An adolescent client who underwent surgery after sustaining a femur fracture while rock climbing is in skeletal traction. For which complications related to immobility is the client at risk? Select all that apply. Anxiety Diarrhea Pneumonia Hypertension Urinary tract infection
Anxiety Pneumonia Urinary tract infection RATIONALE: Immobility is a client's inability to move about freely. Psychological complications of immobility include disorientation, confusion, boredom, anxiety, loneliness, and depression. This adolescent is at risk for complications of immobility. The adolescent who is immobile is at risk for psychological complications, including anxiety, most likely resulting from separation from his or her friends. Gastrointestinal complications of immobility include abdominal distention, constipation (not diarrhea), decreased appetite and weight loss, protein deficiency, and a negative nitrogen balance. Respiratory complications include atelectasis, pneumonia, and decreased gas exchange. Cardiovascular complications include thrombus formation, thrombophlebitis, pulmonary embolism, and orthostatic hypotension (not hypertension). Renal complications include urinary stasis and urinary tract infections, as well as the formation of renal calculi.
Which action on the part of the nurse in the preoperative period is a priority for ensuring that Larry is properly positioned? Assessing the circulation, sensation, and motion of Larry's left foot Positioning Larry on his side periodically to help prevent the development of pressure ulcers Repositioning Larry to decrease the uncomfortable pulling sensation imparted by the traction Positioning Larry on the side of the bed nearest his overbed table so he can reach his things
Assessing the circulation, sensation, and motion of Larry's left foot RATIONALE: It is essential to check the circulation, sensation, and motion of Larry's left foot to detect any diminished tissue perfusion that might be caused by compression of blood vessels and nerves as a result of the traction. Larry will need to remain on his back to keep the traction and his body aligned. Analgesics would be used to decrease the discomfort from the traction. Larry should be positioned in the middle of the bed to help ensure his safety and to prevent misalignment of the bones.
A home care nurse is providing instructions to a client who is having difficulty sleeping about measures to promote sleep. Which instructions should the nurse provide to the client? Select all that apply. Avoid taking naps during the day. Eat a light snack at bedtime if hungry. Be sure that the room is kept very warm. Engage in aerobic exercise just before bedtime. Leave the television or radio on when going to bed.
Avoid taking naps during the day. Eat a light snack at bedtime if hungry. RATIONALE: To promote sleep, the nurse should encourage the client to get up at the same time each day and to avoid naps during the day. A light snack at bedtime may help induce sleep if the client is hungry at that time. However, heavy meals at bedtime should be avoided. The room temperature should be comfortable, neither very cold nor very warm. Daily exercise is important but should be done in the morning or afternoon; vigorous exercise should be avoided in the evening within 3 hours of bedtime. Distracting activities (e.g., watching television or listening to a radio) should be avoided.
A nurse is preparing to assist a hospitalized client with personal hygiene. Which intervention would be best in this situation? Asking the client's spouse to bathe the client. Asking an assistive personnel (AP) to completely bathe the client. Completely bathing the client to conserve the client's energy. Encouraging the client to perform as much of the bath as possible.
Encouraging the client to perform as much of the bath as possible. RATIONALE: While providing hygiene, the nurse must preserve as much of the client's independence as possible. Therefore, encouraging the client to perform as much of the bath as possible is the best option of those provided. Although it may be appropriate to include the client's family in providing care, asking the spouse to give the bath is not the best option. During the bath, the nurse can integrate other nursing activities, including client assessment and interventions such as range-of-motion exercises, application of dressings, skin inspection, and care for intravenous sites, so asking a AP to completely bathe the client is not the appropriate choice. TEST-TAKING STRATEGY: Eliminate the comparable or alike options in that another person is being asked to bathe the client. From the remaining options, note the strategic word "best" and recall that it is best to encourage client independence. Review: the guidelines for providing hygiene care.
Heidi tells the nurse that she thinks she should continue taking the goldenseal because it stimulates the immune system and will help prepare her body for surgery. Which information should the nurse to Heidi? Goldenseal can cause an increase in blood pressure. Goldenseal is helpful in preventing postoperative bleeding. Heidi's surgeon will give her permission to take the goldenseal. Because of its action, goldenseal is acceptable until 1 day before surgery.
Goldenseal can cause an increase in blood pressure. RATIONALE: Goldenseal, an herbal substance, has antiinflammatory and antimicrobial effects and stimulates the immune system. It may increase blood pressure, however, and has anticoagulant effects. Although Heidi may wish to discuss the use of goldenseal with the surgeon, the client who has been scheduled for surgery may be advised to stop taking the herbal substance 2 to 3 weeks before surgery.
A client who is undergoing dialysis for renal failure reports to the nurse in the dialysis center that he was unable to adhere to his prescribed renal diet over a long holiday weekend. As a result, fluid retention has developed. Which foods, as reported by the client, does the nurse suspect were most likely to have contributed to this problem? Select all that apply. Gravy Fresh green beans Cheese dip and canned green chiles Fruit salad with blueberries, pineapple and grapes Cookies flavored with applesauce and spiced with cinnamo
Gravy Cheese dip and canned green chiles RATIONALE: A diet for clients undergoing dialysis to treat a renal disorder is restricted in sodium, calcium, potassium, and pork, beef, and other very-high-protein foods. Among the foods listed, the gravy has a high sodium level. The cheese dip with canned green chiles is high in both calcium and sodium. Fresh green beans, fruit salad with blueberries, pineapple, and grapes, and applesauce do not contain large amounts of potassium. These foods can be consumed by a client undergoing dialysis treatment.
A nurse is caring for a client who has had a cast applied to his arm after fracturing his humerus. The nurse is teaching the client how to care for the injured area once he has been discharged home. Which statements by the client indicate a need for further instruction? Select all that apply. "I should keep my arm in an elevated position as much as possible." "I can expect some numbness and tingling in my fingers for a few days." "I can stick a small object between the cast and my skin if I have an itch." "I should do isometric exercises to make sure my arm muscles stay strong." "If I notice any wet spots on the cast or a funny smell, I should contact my doctor."
I can expect some numbness and tingling in my fingers for a few days." "I can stick a small object between the cast and my skin if I have an itch." RATIONALE: The nurse should teach the client with a casted arm to keep the arm elevated, which will help prevent or ease swelling. The client is also taught the signs and symptoms of infection (e.g., the presence of wet spots on the cast, foul odor). The client should also be taught to perform isometric exercises, which will help prevent muscle atrophy. Numbness and tingling are signs of circulatory compromise, and the client should be instructed to contact the health care provider if these signs are noted. The client must also be instructed not to stick anything inside the cast because of the risk of disrupting skin integrity. The nurse should tell the client that if he experiences itching inside the cast, he may aim a hairdryer adjusted to the cool setting into the cast.
The nurse who scheduled the surgery, performing a preliminary preoperative assessment, discovers that Heidi is taking milk thistle and goldenseal. Heidi says to the nurse, "I don't understand why I have this problem. I take the milk thistle faithfully and still end up with gallstones. Should increase the dose?" Which action should the nurse take? Informing Heidi that the milk thistle must be discontinued Telling Heidi that the milk thistle has no effect on the gallbladder Telling Heidi that herbal supplements never have a beneficial effect on the body Advising Heidi to increase the dose as long as it doesn't exceed the recommended dosage
Informing Heidi that the milk thistle must be discontinued RATIONALE: Milk thistle, an herbal substance, is an antioxidant. It stimulates the production of new liver cells, reduces liver inflammation, and protects the liver from damage. It is used in liver and gallbladder disease. The client would not be told to increase the dose. Reactions may occur when herbal substances are taken with prescription medications, and a client who has been scheduled for surgery may be advised to stop taking the herbal substance 2 to 3 weeks before surgery.
The nurse is developing a plan of care for a client in skeletal traction. Which interventions should the nurse include in the plan of care? Select all that apply. Expect to note some purulent drainage from the pin sites. Ensure that there are no knots in any of the traction ropes. Monitor color, motion, and sensation in the affected extremity. Lift the weights only when it is necessary to reposition the client. Ensure that the weights for the traction device hang freely and do not touch the floor.
Monitor color, motion, and sensation in the affected extremity Ensure that the weights for the traction device hang freely and do not touch the floor. RATIONALE: Traction is the exertion of a pulling force in two directions as a means of reducing and immobilizing a fracture. Nursing responsibilities for the client in traction include ensuring proper body alignment of the client, ensuring that weights hang freely and do not touch the floor, refraining from removing or lifting the weights without a health care provider's prescription, ensuring that pulleys are not obstructed and that the ropes in the pulleys move freely, and tying knots in the ropes to prevent slippage. The nurse should also monitor the color, motion, and sensation of the affected extremity frequently; changes could indicate circulatory compromise and could require health care provider notification. Purulent drainage, which is not an expected finding, is an indication of infection.
Which aspects of care should the nurse include in the plan of care? Select all that apply. The nurse should check to see that skin integrity remains intact. The nurse should ensure that the foot of the bed is kept flat. A straight pull on the limb must be maintained. The weights must hang freely over the edge of the bed. The client should be maintained in high Fowler position on his side.
The nurse should check to see that skin integrity remains intact. A straight pull on the limb must be maintained. The weights must hang freely over the edge of the bed. RATIONALE: A boot or other device is applied to the client's leg when Buck traction is used, and the nurse must assess skin integrity frequently. The foot of the bed should be elevated to provide countertraction. Keeping the foot of the bed level might allow the weights to touch the floor, where they would no longer provide traction to the leg. The weights must hang freely and must apply a straight pull to ensure approximation of the edges of the fracture. The client must be in low Fowler position and on his back to keep the bones in proper alignment.
A nurse is observing as a nursing student prepares and administers a tap water enema to an adult client. Which observation by the nurse indicates the need to intervene before allowing the nursing student to proceed? The student inserts the tube 1 inch into the client's rectum. The student places the client in the left-side Sims position. The student clamps the tubing when the client complains of abdominal cramping. The student checks the temperature of the enema solution before administering it.
The student inserts the tube 1 inch into the client's rectum. RATIONALE: In an adult client, the rectal tube is pointed in the direction of the client's umbilicus and inserted 3 to 4 inches. If the rectal tube were inserted just 1 inch, solution would leak from the anus instead of flowing into the rectum. The rectal tube is inserted 2 to 3 inches in a child and 1 to 1.5 inches in an infant. Putting the client in the left-side Sims position, checking the temperature of the enema solution, and clamping the tubing if the client complains of abdominal cramping are all correct procedures in the administration of an enema.
A client in whom prostate cancer has just been diagnosed is told that surgery followed by chemotherapy will be necessary. The client says to the nurse, "A friend of mine came to visit me last night and told me that I should try complementary therapy. Do you do that here in this hospital? Do you think I should try it?" How should the nurse respond to the client? "You need to ask your doctor about it." "I'd try anything I could if I had cancer." "No, we don't do that here, and besides, it will interact with the chemotherapy." "There are many different forms of complementary therapies. Let's talk about them."
There are many different forms of complementary therapies. Let's talk about them." RATIONALE: Complementary and alternative therapies are a wide variety of treatment modalities that are used in addition to conventional treatment. These therapies should be approved by the client's health care provider to ensure that the treatment does not interact with prescribed therapy. Although the health care provider should approve the use of a complementary therapy and although the use of some of these therapies may interact unfavorably with prescribed treatments, these statements are inappropriate. "I'd try anything I could if I had cancer" is inappropriate and does not address the client's question. The nurse should address the client's question and encourage discussion.
A client with hyperlipidemia has been prescribed a high-fiber diet. Which items should the nurse instruct the client to include in the diet? Select all that apply. Pasta Whole grain cereal White rice Apple juice Whole-wheat bread
Whole grain cereal Whole-wheat bread RATIONALE: Whole-grain products (e.g., whole-wheat bread, cereal) are high in fiber. Refined grain products (e.g., white bread, white rice, pasta, cereals that are not whole-grain) are low in fiber. Vegetables and fruits without skins and seeds (e.g., canned fruit and fruit juice) are also low in fiber.
A nurse has provided information to a client about measures to promote a normal urinary pattern and prevent urinary tract infections. Which statement by the client indicates the need for further information? "I should take my diuretic in the morning." "I should drink plenty of fluids during the day." "I should eat foods that will make my urine acidic." "I should try to hold my urine as long as I can rather than going to the bathroom when I feel the urge."
"I should try to hold my urine as long as I can rather than going to the bathroom when I feel the urge." RATIONALE: As a means of promoting normal urination, the client should be instructed to urinate at regular intervals and when the urge to void is felt. Holding the urine in the bladder may lead to urinary stasis, possibly resulting in infection. The client is encouraged to consume foods and fluids that will acidify the urine (e.g., cranberry juice, meats, eggs, whole-grain breads, cranberries, prunes, plums) and to drink 2000 to 2500 mL of fluid daily to flush microorganisms from the urethra. Diuretics are prescribed to be taken in the morning to prevent nocturia.
After Louis has been home for a few days, the nurse calls Louis to follow up on his progress. Which comments indicate a need for follow-up? Select all that apply. "I'm voiding a lot of urine." "I'm not having any urine leakage." "I have burning when I go to the bathroom." "I still have trouble starting the urine stream." "I don't like the bladder retraining exercises, but I'm doing them."
"I'm voiding a lot of urine." "I have burning when I go to the bathroom." RATIONALE: In this client, who has diabetes mellitus, voiding a lot of urine may indicate hyperglycemia. A burning sensation during voiding may indicate an infection. These findings indicate the need for follow-up. Not having urine leakage is one goal of a bladder retraining program. Louis' statement that he dislikes the bladder retraining exercises does not require follow-up, because Louis indicates that he still is doing them. Difficulty starting the urine stream is probably a result of the benign prostatic hypertrophy and not a new occurrence for Louis.
Since Louis began the bladder retraining program, the incidence of incontinence has decreased. Louis tells the nurse that when it is time to urinate, he now sometimes has difficulty starting the flow of urine. Which instruction should the nurse give to Louis? "Wait an hour, then try again to urinate." "Sit on the toilet to urinate instead of standing." "Bear down and force the urine to begin flowing." "Turn the water on in the bathroom sink and listen as it runs."
"Turn the water on in the bathroom sink and listen as it runs." RATIONALE: The components of a bladder retraining include teaching the client exercises to strengthen the pelvic floor; initiating an individualized toileting schedule based on the client's urination pattern, including frequency and times of urination; using alternative methods (e.g., running water) to aid relaxation and stimulate urination; and teaching the client to take prescribed diuretics in the morning and to consume foods and fluids that increase diuresis early in the day. The client should be encouraged to assume the best position for the initiation of urination. Men generally urinate best from a standing position, whereas women generally sit on the toilet. The client should follow the individualized voiding schedule and should not bear down to force urine flow. Rather, the client should relax the muscles of the perineal floor.
A nurse is caring for a client with a continuous bladder irrigation (CBI). The nurse notes that at the end of the shift a total of 3475 mL of irrigation fluid instilled and a total of 4725 mL was emptied from the urinary catheter bag. The nurse determines that the client's actual urine output is how many mL?mL
1250ml RATIONALE: To determine the actual urine output for a client receiving a continuous bladder irrigation, the nurse would subtract the amount of irrigation fluid instilled into the bladder from the total urine output. Therefore, if 4725 mL was emptied from the urinary catheter bag and 3475 mL of irrigation fluid was instilled, the actual urine output is 1250 mL.
The nurse is preparing to perform an initial assessment of an Asian-American client with a diagnosis of acute pancreatitis. What aspect should the nurse consider while conducting the assessment? Clients of Asian descent may avoid the outward expression of pain. Clients of Asian descent express pain only to others of the same culture. Clients with acute pancreatitis often experience pain that is alleviated by eating. Clients with acute pancreatitis often do not experience pain resulting from the condition.
Clients of Asian descent may avoid the outward expression of pain. RATIONALE: During the assessment, the nurse considers the client's culture, because cultural variations exist with regard to such factors as diet, religion, treatment, and the pain experience. The nurse must remember that although some Asian-American clients will express pain and the need for comfort interventions to the health care provider, others may avoid the outward expression of pain. Therefore, the nurse must be alert to nonverbal expressions of pain in the client. Acute pancreatitis is accompanied by unrelenting pain in the upper left quadrant of the abdomen that radiates to the back. Eating triggers the release of pancreatic enzymes, worsening the pain. Therefore nothing-by-mouth status is instituted for clients with acute pancreatitis.
The nurse is developing a postoperative plan of care for Larry. Which concerns does the nurse have for Larry related to the assessment data noted in the nursing progress notes? Select all that apply.Nursing Progress Notes - Larry Moss Loneliness Constipation Inability to void Inability to cope Inability to clear airway
Constipation Inability to clear airway RATIONALE: Two complications of immobility are respiratory problems such as atelectasis or pneumonia and constipation. Larry's abdomen is slightly firm, with decreased bowel tones, and his last bowel movement was 2 days ago; this places him at risk for constipation. His lungs have crackles and his respiratory rate is increased, which supports the inability to clear airway concern. He does not have inability to void because he has an adequate output. There is no data to support loneliness or inability to cope.
Because Heidi does not want to take medication to relieve her pain, the nurse intervenes and instructs Heidi in the use of imagery to help her relax and help relieve the pain. What should the nurse tell Heidi to do? Listen to the music coming from the bedside radio Focus on the pain and relax the abdominal muscles Tense her leg and arm muscles and focus on those areas Create a mental image of something positive, then relax and focus on the image
Create a mental image of something positive, then relax and focus on the image RATIONALE: Imagery is the process of using mental images to create a desired state (e.g., pain relief). Listening to music is a type of mind-body intervention known as music therapy. Focusing on the pain and tensing the muscles would increase Heidi's incision pain.
During the admission assessment, the nurse asks Louis about the medications he is currently taking. Which medication does the nurse recognize as a possible contributor to the urine retention? Furosemide Humulin N insulin Humulin R insulin Diphenhydramine
Diphenhydramine RATIONALE: Diphenhydramine is an antihistamine and can cause urine retention. This medication must be used with caution in a client with diabetes mellitus or prostatic hypertrophy. Other medications that can cause urine retention include anticholinergic drugs, some antihypertensive agents, and beta-adrenergic blockers. Diuretics (e.g., furosemide) increase urine output. Insulin does not cause urine retention.
A nurse caring for a client who is immobilized and restricted to bed notes that the client is expectorating secretions that are clear but thicker than expected. The client's temperature is 98.6° F (37.0° C) and lungs sounds are clear bilaterally. Which action should the nurse take first? Contacting the client's health care provider Encouraging increased fluid intake Consulting with the health care provider about initiating antibiotics Encouraging the client to cough and deep-breathe at least every 4 hours
Encouraging increased fluid intake RATIONALE: The immobile client should take in at least 2000 mL of fluid daily, if not contraindicated, to help keep mucociliary clearance normal. In clients free of infection and with adequate hydration, pulmonary secretions will appear thin, watery, and clear. The client can easily remove the secretions by coughing. Without adequate hydration, secretions are thick and difficult to remove. There is no information in the question to indicate that the health care provider should be notified or that the client needs antibiotics. The client should be encouraged to cough and deep-breathe every 1 to 2 hours; every 4 hours is too infrequently. Additionally, coughing and deep breathing will not thin the secretions as fluids will.
After Heidi undergoes cholecystectomy, she is transferred to the recovery area in the ambulatory care unit. Heidi indicates during an assessment that she is experiencing incision pain and rates it at 8 on a scale of 1 to 10, with 10 being the worst pain possible. Heidi says she prefers not to take medication to relieve it, however. Which of the following measures that does not require a health care provider's prescription does the nurse plan to relieve Heidi's pain? Select all that apply. Zinc Ginger Humor Exercise Spiritual measures Relaxation therapy
Humor Spiritual measures Relaxation therapy RATIONALE: Humor, spiritual measures, and relaxation therapy, which can all be implemented without a health care provider's prescription, may help relieve Heidi's pain. Ginger (an antiemetic) and zinc (an antiviral) do not relieve pain. Exercise immediately after surgery could strain the incisions and worsen Heidi's pain.
During preparations for discharge, the nurse teaches Heidi wound care. Heidi tells the nurse that she only wants to use herbal or natural products. Which of the following treatments should the nurse tell Heidi to use? Select all that apply. Taking a shower Applying aloe gel Washing with saline solution Covering the wounds with bandages Washing with hydrogen peroxide Washing with povidone-iodine (Betadine)
Taking a shower Covering the wounds with bandages RATIONALE: The client will have small adhesive bandages on the puncture site incisions after the laparotomy. The client may remove the bandages the day after surgery and take a shower. Because there may be a small amount of oozing from the wounds, a dry bandage will help protect Heidi's clothing in addition to the wounds themselves. Aloe gel is not used on open wounds. The saline solution may sting. Hydrogen peroxide and povidone-iodine, which can damage new epithelial tissue, are not used in a clean, granulating wound.
A nurse is watching an assistive personnel (AP) transfer a client from the sitting position on the bed to a wheelchair. Which observations indicate to the nurse that the nursing assistant is using proper body mechanics? Select all that apply. The AP uses a wide base of support. The AP faces in the direction of movement. The AP bends at the waist to help the client stand. The AP twists the waist and back while pivoting the client. The AP bends at the knees and keeps the trunk erect while helping the client stand.
The AP uses a wide base of support. The AP faces in the direction of movement. the trunk erect while helping the client stand. RATIONALE: To prevent injury, health care staff must use proper body mechanics in moving and lifting clients. The nurse or AP should obtain assistance whenever possible and ask the client to aid in moving and lifting, if he or she is able to do so. The AP uses a wide base of support and keeps the feet about shoulder width apart; faces in the direction of movement; bends and flexes the knees; uses thigh, arm, and leg muscles rather than back muscles; avoids bending or twisting at the waist; and keeps the elbows and the client close to the body during the transfer.
The nurse watches as the assistive personnel (AP) helps Larry use the bedpan. Which action would the nurse mention to the AP as unsafe? Calling for help to reposition Larry Encouraging Larry to help by using the trapeze Twisting her back to help maintain Larry above the bedpan as she removes it Having a broad base of support, with her legs shoulder width apart, as she helps Larry
Twisting her back to help maintain Larry above the bedpan as she removes it RATIONALE: Safe body mechanics must be used by the health care provider assisting a client. Twisting the back and pulling at the same time will strain back muscles. Seeking help in repositioning a client is a safe practice. Encouraging Larry to help will not only help the AP but will also help Larry feel more independent. A broad base of support will help maintain the AP's balance.
