In: Nursing
A nurse is the preparing to transfer a client who is partially weight bearing from the bed to chair .Which of the following actions should the nurse take ?
A : Keep his knees straight when moving the client
B: Position the chair next to bed at 90 angle
C: Have the client bear weight on her stronger leg
D: Stand with his feet together when lifting the client
2: A nurse is preparing to insert a peripheral IV catheter into a client arm .which of the following action nurse take to help dilate the vein ?
A: instruct the client to flex their arm with the hand open
B: Stroke the skin near the vein in an upward direction
C: Apply a cool compares to the vein for 10 min
D: Dangle the client arm over the edge of the bed
3: A nurse is providing oral care for a client who is unconscious .which of the following actions should the nurse take
A: place the client inside lying position
B:Apply mineral oil to the client lips
C: Brush the client daily
D: Rinse the client mouth with an alcohol based mouth wash
4:A nurse is collecting a sputum specimen for culture from a client has a respiratory infection which of following should the nurse take ?
A: Wear sterile gloves when collecting the specimen
B:collect 1 ml of sputum
C:offer the client oral hygiene after the collection
5: A nurse is obtaining informed constant from client who is schedule for surgery .The client states .I don't want to go through with the producer .which of the following actions should the nurse take ?
A: Discuss alternative treatment with the client
B: Express approval of the client decision to not have the procedure
C: Document the clients decision in the medical record
D: Explain to the client the risks involved with not having the procedure
3:
1.Option A. Position the wheel chair at 90 degrees angel. Patient can't able to stand on their leg if he had injury ,if we Carry them we need to flex their knees. For bedridden patient we make Rollin of patient on bed towards the wheel chair and bend our knees and take patient in to arms by supporting shoulders and knees.
2.Option D. Free flowing of blood is needed to insert iv catheter.
3. Option C. Oral Care for unconscious patient is needed to avoid complications like aspirations. To provide oral care we have to provide semi Fowler or Fowler's position ,turn head to one side. Alcohol contained mouth wash cause irritation to buccal mucosa . after completion of oral hygiene need to apple some emollient to lips.
4. Option1. Personal protective equipment is needed to avoid spread of infection form patient to others. For sputum culture at least2 ml of sample is required,if not enough sputum is produced,physician may do chest taping ,and encourage to drink plenty of oral fluids for easy coughing. Before sputum collection doctors advise to wash mouth with normal water to avoid oral bacteria.
5.Option C. Informed concent is the legal record about patient decision about particular treatment. In patient centered care we have to consider patient and their relatives are main decision maker. So we have to document patient decision and need to inform to physician.