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Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

A nurse is caring for an 89-year-old male who has been in the hospital for five days for a urinary tract infection. The patient has been given IV antibiotics and is improving. You walk into the room and notice that the patient is more alert and oriented today compared to his admission and states that he is feeling better. The patient says they can ambulate with a walker and assistance and asks to go to the bathroom. Up to now, they have been using a urinal. You notice in his chart that this would be the first time the patient would ambulate since their admission.
1 .
What questions may the nurse consider to ensure patient safety?
2 .
The patient came in as a “high” fall risk. He was confused, agitated, and would frequently try to get out of bed. Now, the patient is pleasant, alert, and oriented x4. What should the nurse include in her routine assessment?
3 .
How would you respond to the patient if they insisted on getting out of bed, but there is no order for ambulation with assistance?
You are conducting a home health visit for Terrence, who lives alone at home. Terrence has visiting nursing services because of lower extremity wounds. Terrence is a 37-year-old male who weighs approximately 550 lbs (250 kg) and has limited mobility. He can ambulate 10 ft (3 m) before becoming short of breath. When observing the wounds, you see that the skin around one of the wounds is hot, red, and painful. His vital signs are within normal limits except for his blood pressure (170/90) and pulse (120). The patient has had two recent hospitalizations. One was six months ago for osteomyelitis, and the other was two months ago for pneumonia.
4 .
What are some factors that are affecting Terrence’s mobility?
5 .
Which major body systems are being impacted by Terrence’s limited mobility?
6 .
You are a nurse in the intensive care unit and your patient is scheduled for a CT scan of their abdomen. Your patient weighs 250 pounds (113 kg) and cannot assist with a transfer from the bed to the transport stretcher. What would be the safest way to transfer the patient to the stretcher?

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