“I just wear the hearing aids when I go out in public.”
“I take a cotton-tipped swab and clean out my ear canals before I insert the hearing aids.”
“I store the hearing aids in the protective box.”
“I use mild soap and water weekly to soak the plastic parts of the hearing aids after I remove the batteries.”
Don sterile gloves before removing the dentures.
Use a foam swab to pry the upper plate loose before removing it.
Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal.
Leave the dentures in the client’s mouth and use a toothbrush to brush the plates.
Describe the usual dietary intake, including types of foods
Include cruciferous vegetables in the diet daily
Decrease fluid intake to 1,200 mL per 24 hours
Prick the colostomy stoma pouch with a pin
Limit intake of gas-producing beverages such as carbonated sodas
Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp
Apply an external catheter
Assist the client to stand at the bedside to attempt to void
Assess the pain level of the client and administer medication appropriately if in pain
Assist the client to the bathroom and turn on running water within hearing distance of the client while the client attempts to void
Discuss relaxation techniques and ask the client to imagine being at home and voiding in his own home bathroom
Explain that the client should void within 8 hours of surgery or return to the hospital for catheterization.
The client drinks 2,000 mL of fluids daily; including 4 ounces of prune juice.
The client has had a soft, formed bowel movement without straining every other day for the past 2 weeks.
The client self-administered one disposable enema the day of last month’s appointment.
The client has minor discomfort from hemorrhoids during bowel movements.
Has elbows bent at a 30-degree angle
Is bent over the walker
Lifts the walker while walking; holding it about 2 inches above the floor
Has a walker that has four wheels in place
The great toe is dorsiflexed and the other toes are fanned out.
The feet are unable to be maintained perpendicular to the legs.
The client is unable to move feet into a position of plantar flexion.
The client is only able to dorsiflex the feet bilaterally.
Before moving the client, family caregivers should raise the hospital bed to the level of their waists. After completing the move, the bed must be returned to the lowest level.
The pillow should be removed from under the client’s head when positioned in a dorsal recumbent position.
Family members should tighten their abdominal muscles and buttocks while keeping their feet about 12 inches apart when using a lift sheet to pull the client up in bed.
The client’s heels should rest on the bed surface and feet kept in a position perpendicular to the legs when the client is lying on the back.
If ambulating 10 times daily for 5 minutes at a time, wearing the hose is unnecessary.
The most appropriate time to apply the hose is before standing to get out of bed in the morning.
If the hose becomes painful to the skin underneath, notify the nurse and request pain medication.
Only cross the legs while wearing the antiembolism hose; otherwise keep the legs uncrossed.
Alter tissue sensitivity by producing numbness.
Decrease the metabolic needs of the involved tissues.
Stop the local release of histamine in the tissues.
Increase blood flow and improve capillary permeability.
Applying ice directly to the ankle
Soaking the foot in warm water for 20 minutes, three times per day
Applying ice continuously to the ankle
Resting and elevating the limb as much as possible
Ask the client for permission to open all containers, remove lids from items on the food tray, and cut up meats
Obtain built-up silverware for the client to use
Observe the client but do not provide assistance if the client is having difficulty
Feed the client if the client is eating too slowly
Ensure that the client is wearing prescribed dentures, eye glasses, or hearing aids before starting to eat
Asking the client to recall the food and beverages consumed on a normal day.
Asking the client to recall the food and beverages consumed on the day the calorie count is initiated.
Informing the client that a record is being maintained of food and beverages consumed.
Asking the client to approximate how many times per week certain food groups, such as cereals and breads, are eaten.
Asking the client to wear supportive shoes before stepping on the scale
Ensuring that the scale is calibrated and “zeroed” before a weight is obtained
Weighing the client by moving the sliding indicator until the scale balances
Weighing the client at different times of the day
Utilizing two staff members to bathe the client quickly while limiting the client’s ability to physically resist
Creating a calm environment during a bed bath by including music and dimmed lighting
Allowing clients, who are willing and able, to participate in some of the hygiene activities
Assessing and treating clients for pain before initiating hygiene activities
Washing the hair and body separately if either activity causes distress or is overwhelming to the client
Keeping the temperature of the bathing area warm and limiting body exposure of clients during bathing
The adult client who underwent ileostomy surgery because of a perforated bowel
The adult client who has a frequent, productive cough and is receiving oxygen by nasal cannula
The adult client who developed thrombocytopenia after receiving chemotherapy
The adult client with hypothermia
Document the other vital signs and note that proper blood pressure (BP) equipment is not available
Contact the nursing supervisor, obtain a small, adult BP cuff, and take the client’s BP with the small, adult-size cuff
Use the adult size BP cuff to obtain the blood pressure, add 10 to both the diastolic and systolic readings, and document on the client’s record the BP was obtained with an adult cuff
Take the client’s BP using any available cuff
Assess the client for dizziness and assess the skin on the extremities for warmth
Obtain a manual blood pressure cuff and retake the client’s blood pressure
Elevate the head of the client’s bed
Read the client’s medical record and determine the client’s normal range of blood pressure
Check the setting to know the type of measurement reading, such as oral or core temperature.
Irrigate the ear canal with sterile saline 6 hours before obtaining the temperature.
Pull downward on the pinna in an adult when inserting the thermometer.
Hold the thermometer loosely in the ear until the thermometer sounds that the reading is finished.
Inform the surgeon since the discharge should be cancelled.
Instruct the client to use the incentive spirometer 10 times every hour and drink plenty of fluids and then recheck the temperature in 2 hours
Administer the dose of aspirin 81 mg earlier than the scheduled time
Realize that the temperature is only mildly elevated and was taken during the time of day when temperatures are highest according to normal diurnal deviations
Keeping the baby fully clothed to prevent hypothermia.
Covering the baby’s eyes with eye shields to prevent retinal damage.
Decreasing the number of feedings for their baby to reduce the number of soiled diapers.
Discontinuing the phototherapy if a mild skin rash develops.
Increased urine output
Decreased heart rate (HR)
Decreased blood pressure (BP)
Temperature of 100.4°F (38°C)
Localized pain and tenderness
Well-approximated wound edges
Redness or warmth at the affected site
Purulent drainage at the incision site
Thick, white drainage in the Jackson-Pratt (JP) tubing
Partial-thickness skin loss involving the epidermis, dermis, or both
Full-thickness skin loss involving damage to subcutaneous tissue
Redness with intact skin that client reports as “itchy”
Full-thickness skin loss with undermining and sinus tracks
Monitor the client’s nutritional intake
Assess for pain and premedicate prior to dressing changes
Monitor pedal pulses and capillary refill of affected extremity
Use hydrogen peroxide for cleaning of ulcer wound
Turn and reposition client every 1 to 2 hours
Elevate the extremity on pillows