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NCSBN ON-LINE REVIEW RATIONALE
- D: First of all, Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client comfort will be improvable as well.
- A: Also, Clean the meatus, begin voiding, then catch the urine stream. A clean catch urine is difficult to obtain and requires clear directions. Also, Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. Similarly, As starting and stopping flow can be difficult, once the client begins voiding it’s best to just slip the container into the stream. Other responses do not reflect the correct technique.
- C: Also, Look for the client who has the most imminent risks and acute vulnerability. Also, the client who returned from surgery 2 hours ago is at risk for life-threatening hemorrhage and should be seen first. Furthermore, the 16-year-old should be seen next because it is still the first post-op day. Also, the 75-year-old is potentially vulnerable to age-related physical and cognitive consequences in skin traction should be seen next. Finally, the client who can safely be seen last is the 20-year-old who is 2 weeks post-injury.
Basic Care and Comfort Rationale
1 C: Also, reposition every two hours. Most Noteworthy, clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. Also, by relieving the pressure over bony prominences at frequent scheduling intervals, blood flow to areas of potential injury is maintainable.
2 A: Also, abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
3 B: Finally, Sliced turkey sandwich and canned pineapple. The turkey sandwich is appropriate since it is not highly processable food and canned fruits are low in sodium. Also, all of the other choices contain one or more high-sodium foods.
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