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A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
- A. Instruct the client not to use the Valsalva maneuver
- B. Apply elastic stockings
- C. Review lab values for total protein level
- D. Place pillows under the client's knees & lower extremities
- E. Assist the client to change position often
Correct Answer: B, E
Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation. Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation. Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice D) may promote comfort but does not directly reduce thrombus risk.
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A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all.
- A. Cover errors w/correction fluid, & write in the correct info
- B. Put the date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of the shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting the date and time on all entries is crucial for accurate documentation, ensuring a clear timeline of events for continuity of care and legal purposes.
C: Documenting objective data without opinions maintains professionalism and accuracy, preventing subjective biases from affecting the client's record.
Incorrect Choices:
A: Covering errors with correction fluid can be seen as tampering with records, potentially leading to legal issues and compromising the integrity of the documentation.
D: Using excessive abbreviations can lead to misinterpretations and errors in communication, jeopardizing patient safety and legal clarity.
E: Waiting until the end of the shift to document can result in information being missed or forgotten, impacting the quality of care and legal accountability.
A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction?
- A. I will begin swimming lessons as soon as my baby can close her mouth under water.'
- B. Once my baby can sit up, he should be safe in the bathtub.'
- C. I will test the temp of the water before placing my baby in the bath.'
- D. Once my infant starts to push up, I will remove the mobile from over the bed.'
Correct Answer: B
Rationale: The correct answer is B: "Once my baby can sit up, he should be safe in the bathtub." This statement indicates a need for further clarification because infants are not safe to be left unattended in the bathtub even if they can sit up. They are still at risk of drowning. It is essential for the caregiver to always supervise the baby closely during bath time to ensure their safety. Testing the water temperature (Choice C) and removing the mobile from over the bed (Choice D) are appropriate safety measures. Beginning swimming lessons when the baby can close her mouth under water (Choice A) may be premature but not necessarily dangerous.
A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. This device will keep me from getting sores on my skin.
- B. This thing will keep the blood pumping through my leg.
- C. With this thing on, my leg muscles won't get weak.
- D. This device is going to keep my joints in good shape.
Correct Answer: B
Rationale: The correct answer is B: "This thing will keep the blood pumping through my leg." This statement shows understanding because sequential compression devices help prevent blood clots by promoting blood circulation in the legs. Option A is incorrect as the device does not prevent skin sores. Option C is incorrect as it doesn't specifically address blood circulation. Option D is incorrect as the device does not impact joint health.
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique?
- A. I will straighten my ear canal by pulling my ear down & back.
- B. I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops.
- C. I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.
- D. After the drops are in, I will place a cotton ball all the way into my ear canal.
Correct Answer: B
Rationale: The correct answer is B: "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops." This statement indicates understanding of the proper technique because applying pressure to the tragus helps the ear drops to reach the ear canal. The tragus is a small cartilaginous projection in front of the ear canal that, when pressed, helps to facilitate the passage of the drops into the ear. This action ensures proper distribution of the medication for effective treatment.
Other choices are incorrect:
A: Pulling the ear down and back is a technique used for administering ear drops in children, not adults.
C: Inserting the nozzle snug into the ear can cause injury to the ear canal and eardrum.
D: Placing a cotton ball all the way into the ear canal can prevent the drops from reaching the ear canal and may cause blockage.