A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following problems is the client at risk for developing?
Stasis of secretions
Muscle atrophy
Pressure ulcer
Fecal impaction
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client’s airway?
Encourage isometric exercises.
Suction every 8 hr.
Give low-dose heparin.
Promote incentive spirometer use.
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? (Select all that apply.)
Instruct the client not to use the Valsalva maneuver.
Apply elastic stockings.
Review laboratory values for total protein level.
Place pillows under the client’s knees and lower extremities.
Assist the client to change position often.
A nurse is instructing a client who is postoperative about the sequential compression device the provider has prescribed. Which of the following client statements should indicate to the nurse that the client understands the teaching?
“This device will keep me from getting sores on my skin.”
“This thing will keep the blood pumping through my leg.”
“With this thing on, my leg muscles won’t get weak.”
“This device is going to keep my joints in good shape.”
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? (Select all that apply.)
Hold the cane on the right side.
Keep two points of support on the floor.
Place the cane 15 inches in front of the feet before advancing.
After advancing the cane, move the weaker leg forward.
Advance the stronger leg so that it aligns evenly with the cane.
Which of the following is NOT an area of focus when prepping a patient for surgery?
Assessing the client; establishing a baseline of normal function for the client.
Easing the patient's anxiety.
Educating the patient.
Physically preparing the patient for surgery.
Explain the procedure to the patient's family.
The nurses's role/ responsibility in regards to a patient's informed consent before surgery is
to witness the signature of the client on informed consent form.
explain the risks and benefits of the surgery.
explain the consequences for not having the surgery.
provide alternative treatment options to the patient.
Which of the following things does the nurse need to ensure are completed prior to surgery? (Select all that apply.)
Pre-labs, x-ray, etc. are present
Verify consent forms are signed.
IV started
Pt undressed and in a gown
Pt valuables taken care of (sent home with family or locked in a safe)
Surgical site marked
Patient is bathed and clean
What action has studies shown to have as negative an outcome (or possibly more negative) than smoking?
Poor diet
Sitting
Driving
Bridge jumping
Which of the following is a NOT possible side effect of an immobile patient?
Negative nitrogen balance
Risk for pressure ulcer
Stress incontinence
