The patient's wound has exudate. The nurse knows this exudate occurs when the patient is in which phase of wound healing?
a. proliferative phase c. inflammatory phase
b. maturation phase d. retraction phase
C
During the inflammatory phase, moderate to large volumes of exudate are typically produced. The proliferative phase is the rebuilding phase. The maturation phase is the remodeling phase. This is not a refraction phase of wound healing.
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A nurse is working with a blended family of 1 year with five children aged 3, 7, 13 (twins), and 19. The parents seem overly stressed and anxious and do not seem to work well as a unit. What can the nurse conclude about this family?
A. Communication problems are the core of the parents' stress. B. Economic stressors are impacting the parental dyad. C. The family is in too many developmental stages to master any of them. D. There are too many children to give each one adequate attention.
The nurse traces the path of unoxygenated blood through the respiratory system to the distribution of oxygenated blood to the body. Place the events of reoxygenation in order. (Separate letters by a comma and space as follows: A, B, C, D)
a. Pulmonary artery takes blood to capillary system of the alveoli b. Blood enters the left atria via the pulmonary vein c. Blood enter the left ventricle d. Unoxygenated blood enters the right ventricle e. Blood enters the aorta f. CO2 diffused and oxygen infused into the blood in alveoli g. Unoxygenated blood enters the right atrium
A nurse observes shoulder drop postoperatively in a client who had a radical neck dissection for cancer 24 hours ago. What is the nurse's best action?
A. Reposition the client on the nonoperative side. B. Document the observation as the only action. C. Assess deep tendon reflexes. D. Notify the physician.
Which is a source for standards of care?
a. Textbooks b. Social media c. The nurse's directions d. Blogs