A nurse is caring for an older adult client with dementia. What preventative measures should the nurse institute to reduce the risk of falls?
Ensure client knows how to use the call light, the nurse should respond to all call lights by the client, keep bed in low position, do hourly rounds, ensure adequate lighting, use fall risk alerts and wrist band.
A nurse is providing discharge education to a client regarding home wound care. What manifestations of wound infection should the nurse include in this education?
Immediately report any signs or symptoms of infection. (redness, swelling exceeding 1/2 inch from incision site, tenderness, increased warmth, red streaks near wound, pus, discharge, foul odor, chills, or temperature higher than 100 degrees Fahrenheit). If soreness or pain causes discomfort, apply a cool pack or take prescribed pain medicine.
A client has been diagnosed with Varicella. What type of tier transmission precaution is required? What protective equipment will be required for prevention of transmission?
Airborne precaution and place client in a private room. Masks and respiratory protection devices for caregivers and visitors. Negative pressure airflow exchange in the room of at least 6 to 12 exchanges per hour, depending on the age of the structure
If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection.
List at least five (5) priority considerations when performing a sterile dressing change.
1. Prolonged exposure to airborne microorganisms can make sterile items non sterile. Avoid coughing, sneezing, and talking directly over sterile field
2. Only sterile items may be on the sterile field. There is a 1-inch border that is not sterile.
3. Touch sterile materials only with sterile gloves
4. Consider an object held below the waist or above the chest contaminated
5. Microbes can move by gravity from a nonsterile item to a sterile item
Identify three (3) priority teaching points to include when educating a client to use a cane.
1. Always maintain two points of support on the ground and keep the cane on the stronger side of the body
2. Support body weight on both legs then move the weaker leg forward toward the cane
3. Next advance to stronger leg past the cane
A nurse is caring for a client receiving oxygen therapy. What is the expected reference range when obtaining oxygen saturation level? Identify four (4) reasons the reference range may be lower.
95%- 100% is the expected reference range. Acceptable levels range from 91%-100%. Some states of illness can allow for 85%-89%. Oxygen levels can be slightly lower if the client skin is dark, hypothermia, poor peripheral blood flow, too much light (sun, infrared lamps), low hemoglobin levels, jaundice, movement, edema, and nail polish.
Describe tertiary prevention measures and provide one (1) example.
Aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioni...
