The student nurse who is developing a plan of care for a postoperative patient who underwent abdominal surgery to remove a tumor. The student has chosen Risk for Infection as a nursing diagnosis
Which of the following is the most appropriate goal for this diagnosis? a. The patient's wound drainage will decrease in 2 days.
b. The patient will report decrease in incisional pain by discharge.
c. The progression of infection will be controlled or decreased.
d. The patient will describe signs/symptoms of wound infection.
C
In an acute care setting the goal for the diagnosis Risk for Infection is "to control or decrease the progression of infection." An outcome is "The patient's wound drainage will decrease in 2 days." Decreased incisional pain is an expectation postsurgically and not directly related to infection. Having the patient describe the signs/symptoms of infection will aid in early detection, but not in preventing infection.
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Which statement describes functional nursing?
1. One nurse has responsibility for all the needs for three clients. 2. One nurse has responsibility for all the medications on the unit. 3. One nurse and one nursing assistant have responsibility for ten clients. 4. One charge nurse and one respiratory therapist have responsibility for all clients.
A client with dysfunctional uterine bleeding (DUB) is in the clinic for diagnosis. During the nursing history, the nurse should ask if the client with amenorrhea has a history of:
1. high-fat diet. 2. weight gain. 3. bulimia. 4. athletic training.
The nurse is teaching a parent of a 6-month-old infant with gastroesophageal reflux (GER) before discharge. What instructions should the nurse include? (Select all that apply.)
a. Elevate the head of the bed in the crib to a 90-degree angle while the infant is sleeping. b. Hold the infant in the prone position after a feeding. c. Discontinue breastfeeding so that a formula and rice cereal mixture can be used. d. The infant will require the Nissen fundoplication after 1 year of age. e. Prescribed cimetidine (Tagamet) should be given 30 minutes before feedings.
A client is ordered to receive adrenocorticotropic hormone (ACTH) for multiple sclerosis. Which nursing intervention would be most appropriate to protect this client from the side effects of this medication?
a. Implement infection control measures. b. Administer antiemetics as needed. c. Give laxatives daily and as needed. d. Administer acetaminophen q4h.