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15 Cards in this Set
- Front
- Back
- 3rd side (hint)
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The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wond site. What do these signs suggest?
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Infection
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May cause unexplained fever and tachycardia, unusual wound pain, prolonged paralytic ileus, and separation of the surgical incision.
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Dehiscence
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Produces visible protrusion of organs, usually through an incision.
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Evisceration
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Can result in increased pulse and respiratory rate, decreased blood pressure, restlessness, thirst, and cold, clammy skin
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Hemorrhage
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The nurse is demonstration how to clean dentures for a client who hasn't worn them before. During this session, what should the nurse teach the client to do?
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Inspect the dentures for rough or sharp areas
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When cleaning dentures, the client should inspect them for rough or sharp areas, which could lacerate his gums and subsequently lead to infection.
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The client should rinse dentures under ______ runnig water.
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Tepid
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Hot water could change their shape.
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When cleaning dentures over a sink, the client should place a ______ ______ or ______ in the sink to prevent damage if they're dropped.
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Paper towel; washcloth
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The nurse has been teaching a client how to use an incentive spirometer that must be used at home for several days after discharge. Which client action indicates an accurate understanding of the techinque?
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When using an incentive spirometer, the client should take slow, deep breaths to ensure maximum ventilation, whichh elevates the ball (or disc) inside the spirometer. Rapid, shallow breathing doesn't allow maxi um ventilation and lung expansion.
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Then nurse has been teaching a client how to use an incentive spirometer.The client should hold the spirometer ______; when ______, a spirometer requires less effort to raise the ball.
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upright; tilted
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Then nurse has been teaching a client how to use an incentive spirometer.During spirometry, the client should ______ ______ - rather than ______ ______ - to promote maximum ventilation.
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Sit upright; lie suping
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The nurse is caring for a geriatric client with a pressure sore on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize?
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Lean meats and low-fat milk, as the diet should emphasize food that supply complete protein. Protein helps build and repair body tissue, actions which promote healing.
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Legumes provide incomplete protein. Cheese contains complete protein but also fat, which should be limited to 30% or less of caloric intake. Whole grain products suppply imcomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.
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The nurse is about to give a back rub to a client after a complete bed bath. How should the nurse plan to proceed?
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The nurse should massage gently in areas directly over pressure points because vigorous massage could damage tissue.
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The nurse is about to give a back rub to a client after a complete bed bath. The client should be moved (______...), rather than (______...) .
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Near the side of the bed within the nurse's reach; in the middle of the bed
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The nurse is about to give a back rub to a client after a complete bed bath. The nurse should pour lotion onto the palms of her hands to ______ it before it touches the client's back.
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Warm
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The nurse is about to give a back rub to a client after a complete bed bath. To remove excess lotion, the nurse should (______...); ______ ______ could damage tissue.
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Pat the area dry with a towel; brisk rubbing
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