In developing a nursing plan of care for a client who has a ...

[jilianpiloj]

In developing a nursing plan of care for a client who has a venous access device, which of these notations is essential to include?
 
  a. Do not measure blood pressure on the involved side.
  b. Maintain accurate measurement of intake and output at all times.
  c. Provide assistance with activities of daily living.
  d. Require a family member to remain with the client overnight to ensure assistance.

Question 2

A nurse is caring for a client who does not speak English and finds it difficult to communicate with the client. Which of these actions should the nurse take?
 
  a. Ask the health care provider to explain client-care routines to the client.
  b. Request the supervisor to change assignments.
  c. Find an interpreter either in the client's family or from the facility resource pool.
  d. Refrain from speaking to the client, as to prevent confusion.

[joanwhite]

Answer to Question 1

A
When obtaining a blood pressure, the nurse should not use the extremity that has a venous access device, has a dialysis fistula or graft, or is on the same side on which the client has had a mastectomy.

Answer to Question 2

C
When language differences impede communication, alternative methods of communication such as gestures, pictures, or flash cards can be useful tools. Members of a client's family may also be able to bridge the communication gap between nurse or health provider and client. If family members are unable to assist, an interpreter may be required.

[jilianpiloj]

Excellent

[carlsona147]

TYSM