What is the priority nursing diagnosis for the client going home with a surgical wound on the coccyx that is to heal by second intention?
A. Acute Pain
B. Risk for Infection
C. Disturbed Body Image
D. Risk for Deficient Fluid Volume
B
Any wound left to heal by second intention is an open wound and is at risk for infection. Usually, within 2 days after the surgery, discomfort is minimal and the wound is not draining sufficiently for the client's fluid balance to be deficient. The client could have a disturbed body image in this situation, although wounds on the coccyx are not visible to the public. However, the priority in this situation is to prevent infection.
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An obtunded patient is admitted to the emergency department after ingesting a known poison. What must a nurse do to assist with a gastric lavage?
A) Place the patient in a semi-Fowler's position. B) Discard aspirate into the toilet. C) Instill the antidote before aspirating stomach contents. D) Inspect the oral cavity for loose teeth.
A nurse is teaching a class to a group of pregnant women. The nurse correctly teaches that the period during which the highest risk of teratogen-induced gross malformations exists is
a. immediately following preconception. b. during the first trimester. c. during the second trimester. d. during the third trimester.
Which assessment data is the nurse likely to observe in a patient with chronic kidney disease?
A) Serum creatinine of 0.7 mg/dL B) BUN:creatinine ratio of 10:1 C) Serum phosphorous of 3.1 mg/dL D) Parathyroid hormone of 62 pg/mL
The process of taking information that has been uncovered and clarified, and systematically processing it to find an acceptable resolution to the problem, is called:
a. critical thinking c. data clarification b. data collection d. problem solving