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Client safety - ANSWERS-The nurse should help the client lie back down & then explain
to the spouse the need for ambulation to reduce potential postoperative complications.
ROM exercises - ANSWERS-Hinge Joints allow flexion & extension movements. The
humeroulnuar joint at the elbow & is performed by flexing the bicep to move the ulnar to
the humerus & extending the triceps to move the ulnar away from the humerus.
Clear liquid diet - ANSWERS-A client who is on a clear liquid diet has coffee on the tray.
Black coffee is considered a clear liquid, but the nurse should remind the client that no
milk or creamer can be added to the coffee.
Braden risk assessment- turning - ANSWERS-A score of 10 on the Braden risk
assessment scale indicate that the client should be turned frequently. This scale is a
reliable tool used to measure the clients risk for the development of pressure sores.
Sores range from 6-23, with the lower scores indicating the highest risk for pressure
sore development.
, Sleep- insomnia - ANSWERS-Sleeping disturbances, such as insomnia, are most
common in post-menopausal women. A regular routine for bedtime & morning
awakening can help set the carcadian clock. Avoiding caffeine before the hours of sleep
can help with sleep since coffee contains caffeine, a stimulant. Alcohol should be
avoided since it can cause fragmented sleep.
Pain Management - ANSWERS-Until the health care professional responds, the nurse
should provide nonpharmacological pain modalities. Guided imagery & coaching in slow
rhythmic breathing are methods that can be effective in moderate pain management.
Conversion- PO- g/ml- 1000mg = 1 g. 1000 mg: X mL: 200 mg : 5 mL - ANSWERS-
200X= 1000 (5). X= 5000/200 = 25 mL
HIPAA regulations - ANSWERS-The client's condition is protected by the Privacy Rule
under the Health Insurance Portivility & Accountability Act (HIPAA), & the
communication/Marketing department can determine whether or not the client has
authorized disclosure of his or her protected heath information to the media.
Unauthorized disclosure of information is illegal.
Informed consent - ANSWERS-It is the health care professionals responsibility to
ensure that the client understands the risks & benefits for the procedure, & the nurse
only witnesses the signature on the consent form after the client indicates they
understand. The health care provider should be called back to the clients room to clarify
any questions & misconceptions. Explaining the procedure again is the health care
providers responsibility.
Risk for Infection - ANSWERS-One of the most important factors impacting the spread
of infection is the susceptibility of the host. Suppression of the immune system greatly
increases the susceptibility of the host, & if hospitalized, increases the risk for
nosocomial infection.
Side effects assess - ANSWERS-To determine how potential side effects (expected, but
undesirable effects) of a medication my impact a client, the nurse should assess the
client for health alterations related to the medication & its potential side effects.