A nurse is caring for an adolescent client who has a newly fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment. B. Explain the discharge instructions to the client and parents. C. Provide reassurance to the client and parents.A nurse is assisting with the plan of care for an older adult client who is 4hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care? A nurse is providing skin care for a 14-year-old adolescent who is in skeletal traction for a fractured femur. Which of the following actions should the nurse take? Select all that apply. Massage reddened bony prominences. Check skin every 2 hours Cleanse skin with soap-free agents. Use a draw sheet to move client. Elevate the HOB to a 90 ...Select all that apply. One, some, or all responses may be correct. *he nurse makes eye contact with the client. 2. The nurse leans backward during the interaction. 3. *The nurse smiles at the client during the interaction. 4. The nurse shrugs her shoulders in response to a client's question.avoids holding the breath during activity. A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins ... avoids holding the breath during activity. A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins ... The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply. Discuss the complications that the client's may experience if they don't cooperate with the care plan. The nurse should discuss the care plan and its rationale with the client. Calling the physician to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply.Study with Quizlet and memorize flashcards containing terms like The nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone ...A nurse is caring for a client admitted to the nursing unit from the PACU following a craniotomy. The initial nursing assessments should focus on A. intracranial pressure B. pupillary reflexes C. level of consciousness D. airway patency, 3. A nurse is planning to prioritize client care after receiving report and rounded on assigned patients.A nurse is assessing a client who has a fractured left femur and is in skeletal traaction, Which of the following findings should the nurse report to the provider>. A. Ecchymosis of the thigh. B. Serous drainage at the pin site. C. Chest petechiae. D. Muscle spasms in the left leg. C. Chest petechiae. A femur fracture is a condition that involves a broken thigh bone and usually happens due to a strong force or a major accident. The femur consists of two femora connected to the pelvis via the hip joint and to the tibia via the knee joint. A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply. A. Consider that nonverbal cues, such as eye contact, may have different meanings in different cultures B. Respect the client's cultural beliefs C. Ask the client if he has cultural or religious requirements that should be considered in his care D. Explain ... Study with Quizlet and memorize flashcards containing terms like The nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone ... A nurse is assisting with the plan of care for an older adult client who is 4hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?Violence & Abuse Review Questions. A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? (Select all that apply.) A. A 6-year-old is being seen for the 5th time for a urinary tract infection. B. A 3-month-old with a fractured femur. C. Study with Quizlet and memorize flashcards containing terms like The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?, The nurse witnesses a client sustain a fall and suspects that the client's leg may be ... Study with Quizlet and memorize flashcards containing terms like An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain?, The surgical nurse is admitting a client from postanesthetic ... Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply., The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider ... C. "A bone fracture can be the direct result of excess pressure in the fibrous membrane or fascia." D. "Diseases such as neoplasms do not cause bone fractures." E. "The severity of a bone fracture depends on the force of the action against the bone and bone strength." Answer: B, E.Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? a. Inspect the client's skin underneath the boot every 12 hr b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr c. Remove the weights from the ...3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry." 1,3,4,5. The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient? A) The cast will feel cool to touch for the first 30 minutes. B) The cast should be wrapped snuggly with a towel until the patient gets home. C) The cast should be supported ... 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry." 1,3,4,5. The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation.A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1.Fever and bradycardia 2.Fever and hypertension 3.Tachycardia and hypotension 4.Bradycardia and hypertensionViolence & Abuse Review Questions. A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? (Select all that apply.) A. A 6-year-old is being seen for the 5th time for a urinary tract infection. B. A 3-month-old with a fractured femur. C.Select all that apply. - Apply occlusive dressings after rewarming - Elevate affected extremities after rewarming - Massage the areas to increase circulation - Provide adequate analgesia - Provide continuous warm water soaks., The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur.Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient? A) The cast will feel cool to touch for the first 30 minutes. B) The cast should be wrapped snuggly with a towel until the patient gets home. C) The cast should be supported ... Study with Quizlet and memorize flashcards containing terms like Which is an inaccurate principle of traction? -The weights are not removed unless intermittent treatment is prescribed. -The weights must hang freely. -The client must be in good alignment in the center of the bed. -Skeletal traction is interrupted to turn and reposition the client., The nurse is providing instructions to the ...The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? a. Provide pin care b. Medicate the client c. Call the healthcare provider d. Remove 2 pounds, A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. Study with Quizlet and memorize flashcards containing terms like A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an: 1. Binder 2. Ice bag 3. Elastic bandage ... Requires frequent pin care A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct? Which information about this type of traction is correct?A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? Ans: Assess the pin insertion site every 8 hours. Study with Quizlet and memorize flashcards containing terms like A school nurse suspects that a 13-year-old has structural scoliosis. Asking the adolescent to perform which maneuver would be the nurse's priority when gathering data for this condition?, The nurse is caring for a 15-year-old client admitted with suspected bacterial pneumonia. Which nursing action takes priority?, The nurse is ...Select all that apply. - Apply occlusive dressings after rewarming - Elevate affected extremities after rewarming - Massage the areas to increase circulation - Provide adequate analgesia - Provide continuous warm water soaks., The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur.The nurse knows that chlorzoxazone, a centrally acting skeletal muscle relaxant, is commonly used to treat: muscle spasm caused by cerebral palsy. chronic musculoskeletal disorder. lower extremity spasticity. (x) severe muscle spasm. The client sustained an open fracture of the femur from an automobile accident.Study with Quizlet and memorize flashcards containing terms like A school nurse suspects that a 13-year-old has structural scoliosis. Asking the adolescent to perform which maneuver would be the nurse's priority when gathering data for this condition?, The nurse is caring for a 15-year-old client admitted with suspected bacterial pneumonia. Which nursing action takes priority?, The nurse is ... A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? Ans: Assess the pin insertion site every 8 hours. A nurse is assessing a client who has a fractured left femur and is in skeletal traaction, Which of the following findings should the nurse report to the provider>. A. Ecchymosis of the thigh. B. Serous drainage at the pin site. C. Chest petechiae. D. Muscle spasms in the left leg. C. Chest petechiae. Which action should the nurse take?, A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? and more. Study with Quizlet and memorize flashcards containing terms like A child with cerebral palsy is in a management program to achieve maximum potential for ...The nurse is caring for a patient whose fractured left femur was surgically managed with intramedullary (I-M) rodding. The nurse would explain which benefits of this type of fixation? (Select all that apply) 1. It results in only minimal skin scarring. 2. It does not interfere with range of motion. 3. It facilitates direct visualization of the ...Study with Quizlet and memorize flashcards containing terms like The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data?, See google docs for chart on DT and alcohol withdrawal syndrome s/s, A client with a diagnosis of antisocial personality ...Select all that apply. - Apply occlusive dressings after rewarming - Elevate affected extremities after rewarming - Massage the areas to increase circulation - Provide adequate analgesia - Provide continuous warm water soaks., The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur.A nurse is caring for a toddler who has a fractured right femur and is in Bryant's traction. When monitoring to determine if the traction is appropriately assembled, the nurse expects to observe which of the following? a. Skin straps maintaining the leg in an extended position b. Weights attached to a pin that is inserted in the femur c.A nurse who is accompanying the group suspects a fracture of the tibia. To immobilize the suspected fracture, where is the best location to apply the splint?, The nurse is checking on a client with a fractured femur who is in skeletal traction. Which of the following actions is necessary to determine a client's neurovascular status? The nurse is assigned to care for a client in traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1. Ensure that the knots are at the pulleys. 2. Check the weights to ensure that they are off of the floor. 3. Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4.A nurse is caring for an adolescent client who has a newly fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment. B. Explain the discharge instructions to the client and parents. C. Provide reassurance to the client and parents. A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? Ans: Assess the pin insertion site every 8 hours. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a construction worker who fell from the second story of a building site and fractured the femoral neck. Which nursing diagnosis is a priority for the client? Select all that apply. A. Risk for infection B.Impaired physical mobility C. Risk for injury D. Urinary incontinence E. Disturbed body image, Which ...Make sure the head of the bed is kept at a 45- to 90-degree angle. Monitor the weights to be sure that they are resting on a firm surface. Inspect the skin under the boot. The nurse prepares to care for a client with acute cellulitis of the lower leg. A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation which of the following intervention should the nurse include in the plan of care? A) Keep the head of the bed at a 30° angle. B) Reposition the client by logrolling every four hours. Study with Quizlet and memorize flashcards containing terms like The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching?, The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The ...A. Log rolling every 2 hours. B. Isometric exercises of both legs. C. Active range-of-motion exercises of the left leg. D. Passive range of motion to the right leg. C. Active range-of-motion exercises of the left leg. A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur.Study with Quizlet and memorize flashcards containing terms like The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching?, The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The ...A nurse is caring for a toddler who has a fractured right femur and is in Bryant's traction. When monitoring to determine if the traction is appropriately assembled, the nurse expects to observe which of the following? a. Skin straps maintaining the leg in an extended position b. Weights attached to a pin that is inserted in the femur c.Study with Quizlet and memorize flashcards containing terms like A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an: 1. Binder 2. Ice bag 3. Elastic bandage ... Study with Quizlet and memorize flashcards containing terms like When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?, An adolescent has skeletal traction for a fractured femur. Which is the most appropriate nursing intervention for this client?, A female client reports to a nurse that ...Which action should the nurse take?, A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? and more. Study with Quizlet and memorize flashcards containing terms like A child with cerebral palsy is in a management program to achieve maximum potential for ... The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the skin under the edge of the cast. A. Log rolling every 2 hours. B. Isometric exercises of both legs. C. Active range-of-motion exercises of the left leg. D. Passive range of motion to the right leg. C. Active range-of-motion exercises of the left leg. A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Select all that apply. - Apply occlusive dressings after rewarming - Elevate affected extremities after rewarming - Massage the areas to increase circulation - Provide adequate analgesia - Provide continuous warm water soaks., The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur.A femur fracture is a condition that involves a broken thigh bone and usually happens due to a strong force or a major accident. The femur consists of two femora connected to the pelvis via the hip joint and to the tibia via the knee joint. a. apply cream daily to the residual limb. b. cover the residual limb with a nylon sock. c. keep the residual limb elevated. d. expose the residual limb to air. d. expose the residual limb to air. the nurse teaches a client diagnosed with a fractured left femur that is in a cast. the client asks how to keep the muscles of the legs strong during ... a. apply cream daily to the residual limb. b. cover the residual limb with a nylon sock. c. keep the residual limb elevated. d. expose the residual limb to air. d. expose the residual limb to air. the nurse teaches a client diagnosed with a fractured left femur that is in a cast. the client asks how to keep the muscles of the legs strong during ...The nurse knows that chlorzoxazone, a centrally acting skeletal muscle relaxant, is commonly used to treat: muscle spasm caused by cerebral palsy. chronic musculoskeletal disorder. lower extremity spasticity. (x) severe muscle spasm. The client sustained an open fracture of the femur from an automobile accident. A nurse is caring for an adolescent client who has a newly fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment. B. Explain the discharge instructions to the client and parents. C. Provide reassurance to the client and parents.The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3. Study with Quizlet and memorize flashcards containing terms like Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. a. Keep the cast clean and dry b. Allow the cast 24 to 72 hours to dry c. Keep the cast and extremity elevated d. Expect tingling and numbness in extremity e. Use a hair dryer set on a ... Study with Quizlet and memorize flashcards containing terms like Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. a. Keep the cast clean and dry b. Allow the cast 24 to 72 hours to dry c. Keep the cast and extremity elevated d. Expect tingling and numbness in extremity e. Use a hair dryer set on a ... Select all that apply. One, some, or all responses may be correct. *he nurse makes eye contact with the client. 2. The nurse leans backward during the interaction. 3. *The nurse smiles at the client during the interaction. 4. The nurse shrugs her shoulders in response to a client's question.The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3.c. Use a cloth-covered pillow to elevate the clients leg. d. Handle the cast with your fingertips to prevent indentations., 3. A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture? a. Sedentary ...Study with Quizlet and memorize flashcards containing terms like To assess the joints, a nurse asks a client to perform various movements. As the client moves their arm away from the midline, the nurse evaluates their ability to perform, The client with rheumatoid arthritis has been taking large doses of aspirin to relieve joint pain. The nurse should assess the client for:, A client takes ...Nursing Prep U The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? Click the card to flip 👆 Activity and rest Study with Quizlet and memorize flashcards containing terms like Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply., plaster cast teaching, A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? and ...Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?, A nurse is collecting data from an older adult client who is preoperative for a total hip arthroplasty. For which of ...Pediatric Nursing - Adolescent. The nurse reviews the plan of care of an adolescent client with diabetes using an insulin pump. This is the second visit that the client has come without his parent. The client's hemoglobin A1C and blood glucose levels are normal. The client reports that he is playing a sport and has not had any hypoglycemic ... Study with Quizlet and memorize flashcards containing terms like A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an: 1. Binder 2. Ice bag 3. Elastic bandage ...
Study with Quizlet and memorize flashcards containing terms like A client is confined to bed with a fracture of the left femur. He begins receiving subcutaneous heparin injections. What is the purpose of this medication? 1. To prevent thrombophlebitis and pulmonary emboli associated with immobility 2.To promote vascular perfusion by preventing formation of microemboli in the left leg 3.To ... . Bursar
Study with Quizlet and memorize flashcards containing terms like The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data?, See google docs for chart on DT and alcohol withdrawal syndrome s/s, A client with a diagnosis of antisocial personality ...Study with Quizlet and memorize flashcards containing terms like To assess the joints, a nurse asks a client to perform various movements. As the client moves their arm away from the midline, the nurse evaluates their ability to perform, The client with rheumatoid arthritis has been taking large doses of aspirin to relieve joint pain. The nurse should assess the client for:, A client takes ...Bone scan impression indicative of infection, The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. A nurse is caring for an adolescent client who has a newly fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment. B. Explain the discharge instructions to the client and parents. C. Provide reassurance to the client and parents.Chapter 41. 4.5 (4 reviews) 1. The nurse is caring for a patient who has had a plaster leg cast applied. Immediately post-application, the nurse should inform the patient that: A) The cast will cool in 5 minutes. B) The cast should be covered with a towel. C) The cast should be supported on a board while drying.Bone scan impression indicative of infection, The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism.Apr 20, 2014 · The nurse is assigned to care for a client in traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1. Ensure that the knots are at the pulleys. 2. Check the weights to ensure that they are off of the floor. 3. Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4. A. Schedule the child for an abdominal ultrasound. B.Instruct the parent to avoid pressing on the abdominal area. C.Determine if the child is having pain. D. Obtain a urine specimen for a urinalysis. B. A nurse is caring for a child who has acute glomerulonephritis.The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? a. Provide pin care b. Medicate the client c. Call the healthcare provider d. Remove 2 pounds, A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1.Fever and bradycardia 2.Fever and hypertension 3.Tachycardia and hypotension 4.Bradycardia and hypertension Chapter 41. 4.5 (4 reviews) 1. The nurse is caring for a patient who has had a plaster leg cast applied. Immediately post-application, the nurse should inform the patient that: A) The cast will cool in 5 minutes. B) The cast should be covered with a towel. C) The cast should be supported on a board while drying. Study with Quizlet and memorize flashcards containing terms like A school nurse suspects that a 13-year-old has structural scoliosis. Asking the adolescent to perform which maneuver would be the nurse's priority when gathering data for this condition?, The nurse is caring for a 15-year-old client admitted with suspected bacterial pneumonia. Which nursing action takes priority?, The nurse is ... The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply. .