Answer to Question 1
A
If the person wore dentures, reinsert them. If the mouth fails to close, and if it is culturally appropriate to close the mouth, place a rolled-up towel under the chin. Dentures maintain the patient's natural facial expression. Place a small pillow or a folded towel under the head. This prevents pooling of blood in the face and subsequent discoloration. Avoid placing one hand on top of the other. Placing one hand on top of the other can lead to discoloration of the skin. Remove soiled dressings and replace with clean gauze dressings. Use paper tape. Paper tape minimizes skin trauma. Changing dressings helps to control odors caused by microorganisms and creates a more acceptable appearance.
Answer to Question 2
B
Position the patient in semi-Fowler's or Fowler's position. This promotes maximal ventilation, lung expansion, and drainage of secretions. Limiting fluids may not promote respiratory function, and unless a patient is on a fluid-restricted diet, the nurse should not do so. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. Respiratory rate should be assessed before narcotics are administered, to prevent further respiratory depression. Management of air hunger involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physician's order. It is not an independent nursing activity.
The nurse is using Standard Precautions to draw blood.
(A) Scratch test; patient is exposed to allergens through a light scratch on the skin; (B) Positive
Measuring Patient Height
The surgical nurse assists the client into the correct position
Family structure is a vital aspect in the socialization of children.
The homeostatic control of normal body temperature (37°C or 98.6°F).