The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse:
1) Performs oral care
2) Assists the patient out of bed
3) Assists the patient with bathing
4) Changes the patient's operative dressings
ANS: 2 Assists the patient out of bed
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A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?
A) It helps determine the percentage of the total body surface area (TBSA) that is burned. B) The client's condition is likely to deteriorate after 72 hours. C) The wound is susceptible to infections. D) The early appearance of the burn injury may change.
The patient with an extensive abdominal operation is assessed by the nurse as having predictable pain. Analgesics for this patient will be most effective when administered:
1. PRN. 2. once a day. 3. twice a day. 4. around the clock.
A client has overflow incontinence. Which intervention does the nurse add to this client's care plan to assist with elimination?
a. Stroking the medial aspect of the thigh b. Using intermittent catheterization c. Providing digital anal stimulation d. Using the Valsalva maneuver
A patient with a bacterial infection has been placed on antibacterial therapy. Which assessment finding in the patient indicates that the therapy is effective?
a. Red blood cell count is 4,500,000 cells/mm3. b. White blood cell (WBC) count is 8000 cells/mm3. c. Wound drainage is thick and yellow. d. Temperature is 102.4° F.