The nurse is collecting data from a patient with a surgical incision. Which findings indicate to the nurse that a local infection is present? (Select all that apply.)
a. Fever
b. Redness
c. Swelling
d. Headache
e. Loss of appetite
f. General malaise
ANS: B, C
Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. A. D. E. F. Symptoms of generalized infection may include headache, malaise, muscle aches, fever, and anorexia.
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A 40-year-old woman has presented to her primary caregiver because she has been experiencing cyclical breast pain over the past several months. The caregiver's clinical examination reveals no palpable or observable abnormalities
This patient's breast pain is most likely attributable to: A) Neuropathy B) Soft-tissue injury C) An infectious process D) Hormonal fluctuations
A patient taking spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of:
1. Hyperkalemia. 2. Hypokalemia. 3. Hypercalcemia. 4. Hyopcalcemia.
Which actions by the nurse could result in a BP measurement error? SELECT ALL THAT APPLY
a. Placing the diaphragm of the stethoscope over the brachial artery b. Using the same cuff for all pts c. Wrapping the bottom edge of the cuff over the antecubital space d. Releasing the valve quickly to prevent pt discomfort e. Taking a measurement after the pt rests quietly for 5 mins.
The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)
a. Ask whether patient's expectations are being met. b. Prevent injury to the skin and tissues. c. Obtain the patient's perception of interventions. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.