Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care?
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Solution
Home environment evaluation
After discharge, the client is responsible for his own care and health maintenance management. Discharge includes assessing the home environment for determining the client’s ability to maintain his health at home.
Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?
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Solution
Maintenance of adequate oxygenation
For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.
Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling?
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Solution
Having the client perform Kegel exercises
Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain urinary continence. To perform these exercises, the client tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an indwelling Foley catheter increases the risk for infection and should be avoided. The nurse should encourage the client to develop a toileting schedule based on normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or diapers should be used only as a resort.
Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale?
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Solution
The presence of infection may slow the healing process.
Infection impairs wound healing. Adequate blood supply is essential for healing. If inadequate, healing is slowed. Nutritional needs, including protein and caloric needs, increase for all clients undergoing cellular repair because adequate protein and caloric intake is essential to optimal cellular repair. Elderly clients may have decreased blood flow to the skin, organ atrophy and diminished function, and altered immunity. These conditions slow cellular repair and increase the risk of infection.
A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury?
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Solution
Administering anti-inflammatory agents as prescribed
Anti-inflammatory agents help reduce edema and relieve pressure on nerve endings, subsequently reducing pain. Elevating the injured area increases venous return to the heart. Maintaining clean, dry skin aids in preventing skin breakdown. Cool packs, not warm packs, should be used initially to cause vasoconstriction and reduce edema.
Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply.
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Solution
Answer: B, D, E
Correct body alignment, preventing footdrop, and range-of-motion exercises will help prevent contractures. Clustering activities will help promote adequate rest. Monitoring intake and output and weighing the client will help maintain fluid and electrolyte balance.
A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation?
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Solution
Instructing the client to fill a 2-L bottle with water every night and drink it the next day.
Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a 2-L bottle with water every night and drink it the next day is one method for ensuring the client receives at least 2,000 ml of water daily. The client also should be instructed to drink any other fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives should not be used routinely for bowel elimination. They should be used only as a last resort, because clients may become dependent on them. A regular bowel evacuation schedule should be established.
Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?
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Solution
“If I have redness, drainage, or fever, I should call my healthcare provider.”
Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury — require reporting indicates that the client has understood the nurse’s discharge teaching. Follow-up checkups should be encouraged with an emphasis of antibiotic compliance even if the client feels better. There are usually activity limitations after cellular injury.
A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client?
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Solution
Room temperature reduction
For patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary. Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Fluids should be encouraged, not restricted to compensate for insensible losses.
Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?
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Solution
Assessing dietary intake
Assessing dietary intake provides a foundation for the client’s usual practices and may help determine if the client is prone to constipation or diarrhea. Limited physical activity may contribute to constipation due to decreased peristalsis. Turning, coughing and deep breathing help promote gas exchange. Fluid intake should be increased to aid bowel elimination.