During data collection, a surgical patient's great toe demonstrates warmth, redness, swelling, and minimal drainage. The nurse would recognize these symptoms as indicative of which condition?
a. Bacterial colonization
b. Generalized infection
c. Systemic infection
d. Local infection
ANS: D
Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. As the infection progresses, there can be an increase in fever, elevated white blood cell count, decreased blood pressure, mental confusion, tachycardia, and shock. Symptoms of generalized infection may include headache, malaise, muscle aches, fever, and anorexia.
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The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient?
a. Flat on her back with knees flexed to help prevent hemorrhage b. On her side to prevent supine hypotension c. In the semi-Fowler's position to prevent supine hypotension d. In the knee-chest position to reduce pressure on the placenta
A nurse reviewing a patient's care plan notes a goal of "Patient will ambulate 50 feet, three times in the hallway today." According to Bloom, what taxonomic category is this goal?
a. Affective domain b. Physical domain c. Psychomotor domain d. Cognitive domain
The nurse explains that Russell traction is a type of skin traction that:
a. Subluxates the tibia b. Does not interfere with range of motion c. Prevents the knee from flexing d. Supplies continuous pull in two directions
A patient comes into the clinic complaining of being exposed to a coworker who has the flu. The patient is asymptomatic. The nurse anticipates that the physician will order which of the following?
A. flumadine (rimantadine) B. valtrex (valacyclovir) C. ziagen (abacavir) D. crixivan (indinavir)