NUR 160 HESI | latest with complete solution

NUR 160 HESI | latest with complete solution checking for cyanosis in a patient who has a darker skin tone - check the lips and mucous membranes to see if they are dusky in color how to accurately assess a client's baseline BP during a routine health exam - measure the pressure in each arm while the client sits with the arm supported at heart level. (seated or supine) advancing oral intake from NPO - ice chips or water first then advance to a clear liquid and up. best strategy to implement for the client's incontinence - establish a 2-hour voiding schedule. intervention to reduce incidence of UTI in a client with a indwelling catheter - cleanse perineum area with soap and water BID and PRN upset client about a recommendation about a AKA states "If they want to cut off my leg, they should just shoot me instead." how do you respond - ask the client how the surgery might effect his lifestyle. (limp amputation alters he body image and changes a clients ADL, work & recreational activities which triggers grieving process for the client. determining the clients perceptions of the procedure's impact on his lifestyle, this is therapeutic & allows client to discuss his feelings. patient with cancer has been taking opioid analgesics for two years now & requires an increase in dose. client expresses fear of becoming addicted to these drugs - explain that prescribed opiates for cancer pain relief improves quality of life. (this is the main goal of pain management for clients with cancer to minimize pain and improve quality of life.) intervention to help a client cope effectively with chronic pain - encourage using relaxation techniques (effective long-term strategy to help a client control tension, anxiety and cope with chronic pain.) a young woman who is the primary caregiver for her mother who has alzheimer's disease states "Sometimes I hate my mother for living this long and my Dad for dying and not caring for her." How do you respond. - "What do you do to cope with these feelings" (invites the client to share feelings and perceptions is most therapeutic) Native American client with TB keeps his eyes on the floor and does not make eye contact . how do you interpret this behavior - his culture finds sustained eye contact as rude or disrespectful client has influenza and vomiting for 3 days, has poor skin turgor and dry oral mucous membranes what other S/S would you report to the nurse - hypotension and tachycardia food that is highest in protein for a vegetarian diet - Soybeans checking gastric residual volume, 150 ml of gastric contents is aspirated what should you do next - return all aspirated contents to the stomach followed with water and consult the agency policy during insertion of NG tub