EAQ
The registered nurse is evaluating the actions of a nursing student who is providing care to a client with compartment syndrome. Which action of the nursing student does the registered nurse think needs correction? Bivalving the cast Applying cold compresses Loosening the bandage applied Evaluating the client's level of pain Elevating the extremity above heart level
Applying cold compresses Evaluating the client's level of pain Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) presses on and compromises the function of blood vessels, nerves, and tendons that run through that compartment. Applying cold compresses on the affected area results in vasoconstriction and worsens the condition. Elevating the extremity above heart-level may lower venous pressure and slow arterial perfusion. Bivalving the cast decreases pressure. Evaluating the client's level of pain is helpful to administer suitable medication. Loosening the bandage decreases pressure.
A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? The infant cries without noise. Aspiration produces a small quantity of light-yellow or light-green liquid. The tube is inserted to a depth from the ear to the tip of the nose to the sternum. A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.
Aspirated fluid that is either light green or yellow indicates gastric contents. The Nitrazine strip test provides reliable proof that the tube is in the stomach. The tube is in the trachea, not the esophagus; when a tube crosses through the larynx, the infant is unable to vocalize. Although the tube being inserted to a depth from the ear to the tip of the nose to the sternum is the correct measurement of the length of tube to be inserted, it is not a guarantee that the tube is in the stomach. The "whoosh test" is no longer used to verify placement of the tube because evidence has shown that it is not reliable.
What is the best method for a nurse to use to assess an infant's response to oral rehydration therapy? Noting the color of the stools Assessing skin turgor frequently Obtaining the weight at the same time every day Measuring the abdominal girth over the umbilicus
Obtaining the weight at the same time every day Weighing the child daily is the most objective and accurate way to assess fluid loss or gain; weights measured at the same time each day provide daily comparisons. The color of stools is unrelated to fluid balance; noting consistency is more important, though subjective. Although checking the skin turgor is done, it is a subjective finding. Measuring the abdominal circumference is appropriate for assessing the progression of ascites, not for assessing rehydration.
When caring for a client in the early postoperative period after a hemorrhoidectomy, to ensure the client's safety, the nurse will place the client in which position? Supine Side-lying High-Fowler Trendelenburg
Side-lying position helps alleviate pressure on the surgical area. High-Fowler and supine should be avoided; both positions will put undue pressure on the site. Trendelenburg is not indicated as an effective intervention for hemorrhoidectomy postoperative care.
A client has excessive edema. Which is the most objective method a nurse can use to assess the extent of edema? Weighing the client Monitoring the intake and output Performing the Trendelenburg test Assessing the extent of pitting edema
Weighing the client One liter of fluid weighs approximately 2.2 pounds (1 kg); weight reflects subtle changes in fluid balance. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured. The Trendelenburg test facilitates assessment of venous peripheral vascular disease, not the extent of edema. Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client.
The nurse provides dietary teaching for a client with a colostomy. Which response by the client is indicative of successful learning? "I will eat food low in fiber so that there is less stool." "I will eat bland foods so that my intestines do not become irritated." "I will eat everything I ate before the operation and avoid foods that cause gas." "I will eat soft foods that are more easily digested and absorbed by my large intestine."
Clients with a colostomy can eat a regular diet; only gas-forming foods that cause distention and discomfort should be avoided. The amount of stool does not have to be limited; therefore, a low-residue diet is not necessary. The affected tissue has been removed, and healthy mucosal tissue lines the intestine and forms the stoma; therefore, bland foods are not necessary. Nutrients are absorbed by the small, not the large, intestine; a regular diet usually is easily digested and absorbed.
What is a priority intervention for the infant undergoing phototherapy? Covering the infant's face with a soft mask Administering glucose water between breast or bottle feedings Keeping the infant in the supine position with the genitals covered Exposing as much skin as possible by turning the infant every 2 hours
Exposing as much skin as possible by turning the infant every 2 hours Turning the infant permits optimal skin exposure to the phototherapy lights. The infant's face should not be covered; only the eyes should be covered. Glucose water does not promote excretion of bilirubin in the stools. The supine position would expose only the front of the infant to the lights.
What is the optimal nursing intervention to minimize perineal edema after an episiotomy? Applying ice packs Offering warm sitz baths Administering aspirin as needed (prn) Elevating the hips on a pillow
Applying ice packs Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.
A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition? Asking the parents to visit at mealtimes Having a nursing assistant feed the child Providing diversional activity at mealtimes Eliminating the child's between-meal snacks
Asking the parents to visit at mealtimes Dinner is frequently a family activity. Having the parents visit during meals may provide the child with additional emotional, social, and physical support, resulting in improved nutritional intake. The child will be resentful if fed by a staff member. Providing diversional activity at mealtimes may further inhibit the child's nutritional intake. Eliminating the child's between-meal snacks may not influence the child's overall intake; snacks may be preferred and will provide a source of nutrition.
A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, what should the nurse encourage the client to do? Assume a standing position for voiding. Void every four hours and attempt to hold urine between set times. Attempt to void more frequently in the afternoon than in the morning. Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake.
Assuming a standing position for voiding reduces tension (physical and psychologic), facilitates the movement of urine into the lower portion of the bladder, and relaxes the external sphincter (increasing pressure and initiating the micturition reflex). Bladder training should be instituted by encouraging voiding every one to two hours and progressively increasing the time between attempts. Voiding should be encouraged at regular and frequent intervals during waking hours, not just in the afternoon. Four liters is a large fluid intake and is unnecessary; it will result in a large volume of urine, probably increasing the frequency of incontinence.
After a gastrojejunostomy (Billroth II) for cancer of the stomach, a client progresses to a regular diet. After eating lunch, the client becomes diaphoretic and has palpitations. What does the nurse conclude is the probable cause of these clinical manifestations? Intolerance to fatty foods Dehiscence of the surgical incision Extracellular fluid shift into the bowel Diminished peristalsis in the small intestine
Extracellular fluid shift into the bowel Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome). Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with dumping syndrome. Dehiscence is separation of the wound edges, usually accompanied by a gush of pink-tinged fluid. Although peristalsis may be decreased because of surgery, this decrease will not account for the client's clinical manifestations.
A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. How should this be documented in the client's medical record? Urge incontinence Stress incontinence Overflow incontinence Functional incontinence
Overflow incontinence [1] [1] [2] describes what is happening with this client; overflow incontinence occurs when the pressure in the bladder overcomes sphincter control. Urge incontinence describes a strong need to void that leads to involuntary urination regardless of the amount in the bladder. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Functional incontinence occurs from other issues rather than the bladder, such as cognitive (dementia) or environmental (no toileting facilities).
Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process? Promoting vasodilation Cleansing perineal tissue Softening the incision site Tightening the rectal sphincter
Promoting vasodilation Heat causes vasodilation and increased blood supply to the area. Cleansing is performed with a perineal bottle and cleansing solution immediately after voiding and defecation. Sitz baths do not soften the incision site. Neither relaxation nor tightening of the rectal sphincter will speed healing of an episiotomy.
Which theory is based on the model of primacy of caring? Roy's Theory Watson's Theory Betty Neuman's Theory Benner and Wrubel's Theory
The model of primacy of caring is the basis of Benner and Wrubel's Theory. This theory focuses on client's need for caring as a means of coping with stressors of illness. According to Roy's theory, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. This theory promotes health, restoring the client to health, and preventing illness. Neuman's theory is based on stress and the client's reaction to the stressor.
Which treatment is beneficial for a client with muscle spasm? Thermotherapy Muscle massage Frequent position changes Muscle-strengthening exercise regimen Confident
Thermotherapy, the use of heat therapy, eases pain and muscle contraction; therefore it is useful in treating muscle spasms. Muscle massage stimulates muscle tissue contraction and may worsen a muscle spasm. Frequent position changes are beneficial for a client with contracture. A muscle-strengthening exercise regimen is beneficial for a client with muscle atrophy.
A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of which month? Fifth month Third month Fourth month Second month
Third month Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, not the second month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin, but has usually diminished by the fifth month.
An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? Asking the client's parent Using Wong's "Pain Faces" Observing the client's body language Explaining the use of a 0 to 10 pain scale
Using Wong's "Pain Faces" An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.
A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss? Measuring the abdominal girth daily Having the child urinate in a bedpan Testing the child's urine for proteinuria Weighing the child at the same time each day
Weighing the child at the same time each day Comparison of daily weights is the most accurate way to assess fluid retention or loss. Having the child urinate in a bedpan is difficult for a child of this age, and the findings will not be accurate. Measuring the abdominal girth daily is way to assess the degree of ascites; it indirectly measures fluid retention. Assessment of urine for protein gives information about the disease process, but not about the amount of fluid retention.
A client is experiencing chronic constipation, and the nurse discusses how to include more bulk in the diet. Which statement by the client indicates teaching by the nurse is successful? "Bulk promotes defecation by irritating the bowel wall." "Bulk promotes defecation by stimulating the intestinal mucosa chemically." "Bulk promotes defecation by acting on the microorganisms in the large intestine." "Bulk promotes defecation by absorbing water, which softens stool and promotes peristalsis."
"Bulk promotes defecation by absorbing water, which softens stool and promotes peristalsis." Fiber provides bulk. Fiber absorbs water, swells, and softens hard stool, promoting peristalsis, mass movements, and defecation. Bulk caused by fiber does not irritate the bowel wall. There is no chemical stimulation. Bacterial action is not involved in the process by which bulk stimulates defecation.
The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? 150 to 250 mL 250 to 350 mL 300 to 500 mL 500 to 750 mL
500 to 750 mL In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.
A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child? Flexion of the hip Extension of the hip Adduction of the hip Abduction of the hip
Abduction will enable the head of the femur to fit into the acetabulum, thereby correcting the dysplasia. Flexion causes the head of the femur to move away from the acetabulum. Extension causes the head of the femur to move away from the acetabulum. Adduction causes the head of the femur to move away from the acetabulum.
The nurse has taught a client about a low-sodium diet. Which food choice by the client indicates successful learning? Banana Carrots Yogurt Tomato juice
Banana A medium banana contains only 1 mg of sodium. All the rest are higher than a banana. Carrots are low in sodium, but ¼ cup contains 10 mg. Yogurt contains over 80 mg, while tomato juice is the highest.
The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? Dehydration Skin breakdown Electrolyte imbalances Urinary tract infections
Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.
What considerations should be included in caring for an infant who is failing to thrive (FTT)? Dietary history Signs of malnutrition Familial stress factors 75th percentile for weight Parent and infant interaction Sustained growth under 5th percentile
Dietary history Signs of malnutrition Familial stress factors Parent and infant interaction Sustained growth under 5th percentile Dietary history should include type of feedings, because failure to thrive may be a result of an inadequate milk supply in a breast-feeding mother. Signs of malnutrition can affect hair and skin. The infant also may be listless and slow to achieve milestones. Familial stress factors, such as depression and substance abuse, affect the ability of the caregiver to meet the infant's needs. Lack of parent and infant interactions contributes to failure to thrive, because infancy is the time to develop trust or mistrust. Sustained growth under the 5th percentile indicates failure to thrive. It is expected that an infant will double birth weight by 6 months of age. Weight in the 75th percentile indicates thriving.
Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? Skin that is cool to the touch Shrinking of the residual limb Absence of phantom limb pain Evenly darkened skin of the residual limb
Evenly darkened skin of the residual limb Even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a proper fit. Cool skin may indicate inadequate tissue perfusion, which may be caused by progression of the disease, inadequate wound healing, or excessive pressure from the prosthesis. Shrinking of the residual limb results in an improper fit. Absence of phantom limb pain is unrelated to a proper fit.
A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? Ripe bananas Milk products Green vegetables Creamed potatoes
Green vegetables contain fiber, which promotes defecation. Bananas, milk products, and creamed potatoes have a constipating effect, which results in straining at stool.
A 16-month-old toddler has had large, frothy, foul-smelling stools since the introduction of table foods and is irritable and apathetic. The child is diagnosed with celiac disease and a gluten-free diet is prescribed. What response does the nurse anticipate in the child after 2 days on the diet? Return of appetite Increase in weight Improved behavior Cessation of diarrhea
Improved behavior A favorable change in behavior occurs in 2 to 3 days and attests to the effectiveness of the diet; other improvements take longer. A return of appetite takes more than several days of therapy; anorexia redevelops during episodes of diarrhea. An increase in weight and cessation of diarrhea each take more than several days of therapy.
A client is admitted with a fracture of the neck of the femur. In what position should the nurse maintain the client's affected extremity? Internal rotation with flexion of the knee and hip External rotation with flexion of the knee and hip Internal rotation with extension of the knee and hip External rotation with extension of the knee and hip
Internal rotation with extension of the knee and hip A fracture in the neck of the femur will cause shortening of the femur and external rotation. To correct this misalignment, the client's leg should be extended and maintained in slight internal rotation. To reduce the fracture, it is necessary to maintain the leg in extension, counteracting the contraction of the quadriceps that may cause overriding of bone fragments. External rotation of the thigh as a result of muscle contraction tends to misalign the bone fragments; therefore, slight internal rotation or functional alignment is preferred.
A nurse is instructing about nutrition with a client who has inflammatory bowel disease of the ascending colon. Which suggestion by the nurse is most appropriate? Consume scrambled eggs and applesauce Consume barbecued chicken and french fries Consume fresh fruit salad with cheddar cheese Consume chunky peanut butter on whole wheat bread
Low-residue foods produce less fecal waste (eggs and applesauce), decreasing bowel contents and irritation; protein promotes healing, and calories provide energy. Barbecued foods are spicy; foods high in fat can increase peristalsis. Fruit and aged, sharp cheese can be irritating to the bowel. Chunky peanut butter and whole wheat bread are high-residue (high fiber) foods.
A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? No protein Moderate protein High protein Strict protein restriction
Moderate protein Because the liver is unable to detoxify ammonia to urea and the client is experiencing impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no protein restrictions are not required because clients need protein for healing. High protein is contraindicated in hepatic encephalopathy.
A nurse is caring for a client who recently is diagnosed with a gastric ulcer. The nurse expects that the plan of care will include a prescription for which type of diet? Soft diet Low-fat, high-protein liquid diet Hourly feedings of dairy products Regular diet with foods that are tolerated
No specific diet is recommended; the client is encouraged to avoid meals that overdistend the stomach and foods that cause gastrointestinal (GI) distress. There is no need for a soft diet; a soft diet is appropriate for those who have difficulty with chewing and swallowing. The client does not require a liquid diet. High-fat dairy products increase GI secretions and may not be tolerated by some clients.
An infant undergoes corrective surgery for hypertrophic pyloric stenosis. What should the nurse teach a parent to do immediately after a feeding to limit vomiting? Rock the infant. Place the infant in an infant seat. Place the infant flat on the right side. Keep the infant awake with sensory stimulation.
Place the infant in an infant seat.
The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? Stimulate continuous formation of urine. Facilitate the measurement of urinary output. Prevent the development of clots in the bladder. Provide continuous pressure on the prostatic fossa.
Prevent the development of clots in the bladder. A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. Fluid instilled into the bladder does not affect kidney function. Urinary output can be measured regardless of the amount of fluid instilled. The urinary retention catheter is not designed to exert pressure on the prostatic fossa.
A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." What complication should the nurse explain can be prevented by exercising every day? Paresthesias of the feet Shortening of the muscles Development of osteoblasts Loss of muscular coordination
Shortening of the muscles Flexion and extension prevent tightening of muscles and tendons. Abnormal sensations (paresthesias) are related to neurologic, not musculoskeletal, alterations. Weight bearing, not exercise, promotes the development of osteoblasts. Loss of muscular coordination is the result of cerebellar changes; it is not related to immobility.
Three months after beginning chemotherapy, a client develops severe anorexia, stomatitis, and episodes of diarrhea. The nursing plan includes increasing fluid and caloric intake and taking measures to relieve discomfort caused by stomatitis. Which activity should the nurse recommend to address the care plan? Drink water frequently Suck on an ice pop every two hours Swallow warm tea throughout the day Rinse the mouth with the prescribed nystatin after meals
Suck on an ice pop every two hours Ice pops provide calories and fluid, and the cold relieves discomfort associated with the stomatitis. Water does not provide calories, only fluid. Tea has no calories, and cool/cold drinks are advised. Although rinsing the mouth with nystatin after meals may prevent infection, it does not provide calories or fluid.
A pregnant client is diagnosed with gestational hypertension. The client tells the nurse that she has been following the recommended pregnancy diet. What should the nurse teach her about her diet at this time? Limit proteins Change nothing Restrict sodium Increase carbohydrates
The recommended diet for a client with gestational hypertension is the same as that recommended for a normotensive pregnant client. Protein intake should be increased during pregnancy. Pregnant clients with gestational hypertension should not restrict their sodium intake or increase their carbohydrate intake over the recommended amount.
To reduce a fracture of the hip, a client is placed in Buck traction before surgery. Because the client keeps slipping down in bed, increased countertraction is prescribed. What should the nurse do to increase countertraction?
Use a slight Trendelenburg position. Elevating the foot of the bed uses gravity and the client's weight for countertraction. Adding more weight to the traction will increase traction and requires a prescription; also it will cause more, not less, slipping down in bed. Elevating the head of the client's bed will decrease countertraction. Applying a chest restraint around the client will have no effect on countertraction.
The nurse is caring for a client who is wearing a prosthesis after a single-leg amputation. Which crutch gait should the nurse teach the client to use? Tripod Four-point Three-point Swing-through
A four-point gait provides for weight bearing on all points that touch the floor and maximum support during ambulation. A tripod is for clients learning to do a swing-to gait pattern. A three-point gait is used when one extremity cannot bear weight. A swing-through gait does not simulate ambulation; it is used when the individual can bear weight but lacks the muscular control needed for ambulation without an assistive device.
A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant? Frothy stools Weak, rapid pulse Pale, copious urine Bulging anterior fontanel
A weak, rapid pulse is an expected adaptation with a state of severe dehydration because of hypovolemia. Children with untreated cystic fibrosis and celiac disease have frothy stools. There is no indication that this infant has either of these disorders. Severe dehydration results in decreased urine output and concentrated urine. One of the signs of dehydration in an infant is a sunken, not bulging, anterior fontanel.
The nurse is caring for a client who recently was diagnosed with urinary phosphate calculi. What should the nurse plan to teach this client to include in the diet? Pears Hamburgers Baked salmon Cheddar cheese
All fresh fruits are low in phosphate, which should be limited in a client with urinary phosphate calculi. Beef and fish contain phosphate; all protein foods are high in phosphate. Cheddar cheese is made with milk, which contains phosphate; dairy products are high in phosphorus.
A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report? .
Anal itching Blood in stool Rectal bulging Pain when defecating Anal pruritus (itching) occurs as varicosities enlarge and become inflamed. Blood and mucus in the stool occur during bowel movements. Rectal bulging (prolapse) occurs as portal venous pressure increases and varicosities enlarge. Pain occurs when varicosities enlarge and thromboses occur; pain increases on defecation. Flatulence is unrelated to hemorrhoids.
A hospitalized 3-year-old child with leukemia is undergoing chemotherapy. The mother tells the nurse that her child is asking for fried chicken. How should the nurse respond? Fried foods might cause nausea and vomiting during chemotherapy. Any food that is requested should be given because the child needs calories. Coatings on foods to be fried may irritate the child's mouth and cause bleeding. Foods from outside should not be brought to the unit because of the potential for infection.
Any food that is requested should be given because the child needs calories. Because chemotherapy can cause nausea, vomiting, and anorexia, the child should be offered any food that is requested. Even if the nutritional quality is minimal, the child will be receiving needed calories. Fried foods can usually be eaten because generally they do not cause nausea and vomiting or irritate the mouth. Food prepared adequately should not be contaminated and therefore should not cause problems for a child undergoing chemotherapy.
Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item? Apples Chocolate Rye bread Cheddar cheese
Apples Apples are low in phosphate; fresh fruit is low in phosphorus. Chocolate contains more phosphate than apples. Rye bread contains more phosphate than apples. Cheese is made with milk, which contains phosphate and should be avoided. Dairy products are high in phosphorus.
A peripheral nerve or dorsal column stimulator is implanted to relieve a client's intractable pain. What discharge instructions should the nurse provide? Disconnect the transmitter when taking a bath. Analgesics will no longer be necessary. The transmitter will be implanted and, therefore, not visible. The transmitter will interfere with electronic devices.
Clients may bathe when the transmitter is disconnected. The client may need analgesics in conjunction with the transmitter. Electrodes are attached to sensory nerves or over the dorsal column; a transmitter is worn externally and, by electric stimulation, may be used to interfere with the transmission of painful stimuli as needed. The transmitter should not interfere with other electronic devices.
A school-aged child has a cast applied to a fractured wrist. What action should the nurse take to hasten drying of the cast? Use a blow dryer. Expose the casted extremity. Cover the cast with a light sheet. Open a window to promote ventilation.
Exposing the cast is the safest way to dry it evenly; a fan may be used if the humidity is high. Besides the danger of a burn injury to the child, the cast may dry on the outside and remain damp within with use of a blow dryer. Covering the cast impedes circulation of air, which will delay drying. Opening a window is not necessary if the cast is exposed to air.
