ATI VIRTUAL NCLEX REVIEW|UPDATED&VERIFIED|100% SOLVED|GUARANTEED SUCCESS

Braden scale pressure ulcer review s/s of sepsis when you have pressure ulcer tachy hypotension increase WBC fever encourage what vitamins for wound healing A, C, zinc, copper TPN used when GI tract is not functioning very high caloric solution IV in a hypertonic solution administer hypotonic fluids administer hypotonic fluids high sodium low na administer diuretics what na high na implement seziure precautions both na observe for shallow ineffective respiration what k low facial flushing high mg monitor constipation what ca high ca administer 0.9 sodium chloride what ca high ca ECG monitor display what action intra established IV access pre paper, wood rags flammable liquid gases electrical fires A B C client is admitted to the hospital following a seizure that occurred in her home. The client has no previous history of seizuresIn planning the client's nursing care, which of the following measures is most essential at the time of admission? Select all that apply. 1. Place a padded tongue depressor at the head of the bed. 2. Pad the side rails. 3. Inform the client about the importance of wearing a medical identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment. NCLEX Challenge 1. Incorrect. Attempting to insert something into the client's mouth during a seizure is likely to cause more injury. 2. Correct. Padding the side rails will help keep the client safe if another seizure occurs. 3. Incorrect. This step would be taken if it is likely that a seizure would reoccur . Since this is the client's first seizure, more assessment is needed before this measure is deemed necessary. 4. Incorrect. This step would be taken if it is likely that a seizure would reoccur . Since this is the client's first seizure, more assessment is needed before this measure is deemed necessary. 5. Correct . Maintaining oral - suction equipment is appropriate and will keep the client safe in the event of another seizure overwhelm the resources of individual hospitals and resources of entire health system mass casualties who establishes emergency preparedness management JC who triages of incoming clients JC how many emergency preparedness drills each year 2 missing adult what code tornado code bomb purple black yellow how do you reduce friction and shears having client bend the knees and cross arms across chest as you reposition Principles of Body Mechanics • Wide base of support . • Low center of gravity. • Line of gravity must pass through the base of support. • Face the direction of movement. Avoid twisting. • Divide load bearing between arms and legs . Use strong muscles like upper arms, thighs, upper back, and shoulders. (Do not use lower back.) ... trendelenburg used for postural drainage or if umbilical cord relieved reverse trendelenburg GERD modified trendelenburg hypovolemia - shock NG tube clean or surgical clean urinary catheter clean or surgical surgical aseptic Consider any object below the waist or above the chest contaminated true 1- inch border of sterile drapes and packages is considered contaminated tier one tier 2 standard precautions contact, droplet and airborne Bony prominences should be padded and neurosensory checks (loosening or removing the restraint and testing temperature, mobility, and capillary refill) should be performed neurological or circulatory deficits for restraints every 2 hours