A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an
... [Show More] acceptable method for the nurse to use to thin this client's secretions?
⦁ Provide humidified oxygen. → want to hyperoxygenate prior to suction
⦁ Perform chest physiotherapy prior to suctioning.
⦁ Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
⦁ Hyperventilate the client with 100% oxygen before suctioning the airway..
⦁ Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
⦁ Rub the client's feet briskly for several minutes.
⦁ Obtain a pair of slipper socks for the client.
⦁ Increase the client's oral fluid intake.
⦁ Place a moist heating pad under the client's feet.
⦁ A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
⦁ Emesis of 100 mL
⦁ Oral temperature of 37.5° C (99.5° F)
⦁ Thick, red-colored urine
⦁ Pain level of 4 on a 0 to 10 rating scale
⦁ A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?
⦁ Shivering → The process of shivering is detrimental since it counteracts cooling induction, consumes energy, and can contribute to increased ICP, increased energy expenditure and brain O2 consumption.
⦁ Infection
⦁ Burns
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⦁ Hypervolemia
⦁ A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the
teaching?
⦁ "I will carry a complex carbohydrate snack with me when I exercise."
⦁ "I should exercise first thing in the morning before eating breakfast."
⦁ "I should avoid injecting insulin into my thigh if I am going to go running."
⦁ "I will not exercise if my urine is positive for ketones." → not having enough insulin to use, the sugar in the blood can also cause the body to burn fat for fuel.
When the body starts to burn fat for fuel, substances called ketones are produced. People w/diabetes shouldn’t exercise if the have high levels of ketones in their blood because it can make them really sick & cause their insulin levels to increase. [Show Less]