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skin tenting
answers: a sign of fluid volume deficit (dehydration)
community-based nurse intervention for cocaine addiction
answers: Assess the frequency of abuse, Assess the nature of use, Assess the
amount of consumption
purpose of client's restraints
answers: The restraints discourage the client from ambulating alone.
proper order of abdominal assessment steps
answers: Inspections (eyes), auscultation, percussion, palpate
focused assessment
answers: assessment conducted to assess a specific problem; focuses on pertinent
history and body regions
initial action for abdominal pain assessment
answers: Assess the symptomatic quadrant last; start with furthest away from the
problem and work your way
subjective assessment finding in postoperative client
, answers: pain description
nurse's legal responsibility when applying restraints
answers: Document the client's behavior, Document the type of restraint used,
Obtain a written order from the physician except in an emergency, when the client
must be protected from injury to himself or others.
priority intervention for indwelling catheter client
answers: Check to see if the catheter is patent
teaching plan for client with diarrhea
answers: Drinking at least eight glasses of fluid each day
techniques for administering a cleansing enema
answers: Assist the client to a left side-lying (Sims) position, Raise container,
release clamps, and allow solution to fill tubing before administration.
Clamp tubing after solution is instilled
answers:
Raising the head of the bed
answers: Assists the patient into a more normal position that allows proper
contraction of muscles for elimination.
Peristalsis in the stomach