Mobility & Immobility
When assisting a client with one-sided weakness to walk with a cane, the client should hold the cane on this side of the body.
What is the unaffected (strong) side?
A client on a "clear liquid" diet is allowed to have apple juice, gelatin, and this caffeinated beverage (without cream).
What is black coffee?
This type of incontinence occurs when a patient leaks urine while coughing, sneezing, or lifting heavy objects.
What is Stress Incontinence?
This "fifth vital sign" should be assessed regularly and managed based on the client's self-report.
What is pain?
To prevent pressure ulcers, an immobile client should be repositioned at least every ____ hours.
What is 2 hours?
This position, where the head of the bed is elevated 45 to 60 degrees, is ideal for a patient eating a meal to prevent aspiration.
What is Fowler's position?
To verify the initial placement of a newly inserted Nasogastric (NG) tube, this is the most reliable method.
What is an X-ray?
To prevent Urinary Tract Infections (UTIs) in female clients, the nurse should teach them to wipe in this direction.
What is front to back?
This non-pharmacological comfort measure involves using a rhythmic stroke to promote relaxation and improve circulation.
What is therapeutic massage (or back rub)?
This stage of a pressure injury is characterized by non-blanchable erythema (redness) of intact skin.
What is Stage 1?
To prevent contractures and muscle atrophy in an immobile patient, the nurse should perform these exercises at least twice a day.
What are Range of Motion (ROM) exercises?
This Vitamin is essential for the absorption of calcium and is often called the "sunshine vitamin."
What is Vitamin D?
This is the primary dietary recommendation for a client suffering from chronic constipation.
What is increasing fiber and fluid intake?
Clients with Sleep Apnea should be advised to avoid this substance before bedtime as it relaxes the upper airway muscles.
What is alcohol?
When performing perineal care for an uncircumcised male, the nurse must remember to do this to the foreskin after cleaning.
What is replace (reduct) it?
When a patient is using crutches to go up the stairs, they should lead with this leg first.
What is the unaffected (good) leg?
For a patient with dysphagia, the nurse should provide this type of liquid consistency to reduce the risk of choking.
What is thickened liquids (nectar or honey thick)?
A client with a new ileostomy will have stool that is consistently this texture.
What is liquid (or loose)?
This term describes the phenomenon where a patient feels pain in a limb that has been surgically removed.
What is Phantom Limb Pain?
This scale is a common tool used by nurses to predict a patient's risk for developing pressure sores.
What is the Braden Scale?
This serious complication of immobility involves a blood clot in a deep vein, often presenting with unilateral calf swelling and redness.
What is Deep Vein Thrombosis (DVT)?
Total Parenteral Nutrition (TPN) must be administered through this type of venous access because of its high glucose concentration.
What is a Central Line (or Central Venous Catheter)?
When performing a 24-hour urine collection, the nurse must do this with the very first voiding of the morning.
What is discard it?
This is the most common side effect of opioid analgesics that the nurse must monitor for regarding safety and elimination.
What is constipation?
This type of wound drainage is thin, watery, and pale red or pink in color.
What is Serosanguineous drainage?