The nurse is caring for a patient who has a stage 4 pressure ulcer that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which patient assessment finding should be communicated to the RN immediately?
a. Yellow wound drainage
b. A reddened area adjacent to the ulcer
c. Patient report of pain
d. Pink grainy appearance at wound edges
ANS: B
A reddened area adjacent to the ulcer can indicate extension of the ulcer or infection and should be reported. Yellow drainage may indicate colonization and not true wound infection. Pain is not unexpected and can be treated by the LPN. Pink grainy appearance is a sign of healing.
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The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and he has no intention of getting out of
bed. What is the nurse's best response? a. "It's important to move around so you don't get a blood clot in your leg." b. "Your doctor ordered that you are to get out of bed at least twice every day." c. "I understand. You can rest in bed until tomorrow when the pain is better." d. "I will call the doctor and let him know that you do not want to get up."
You are a nurse manager in a facility that is part of a national system of specialized hospitals that provide services to children and that is funded and managed through a religious charity organiza-tion
This system emphasizes compassionate, faith-based care. What level of consolidated system is represented in this example? a. First level b. Second level c. Fourth level d. Fifth level
If a DVT (deep vein thrombosis) is suspected, the nurse should:
a. perform a Homans sign on the affected leg. b. dorsiflex the foot of the affected leg. c. palpate the affected leg for edema and pain. d. place the client on bed rest, with the affected leg elevated.
The nurse recommends to the mother of a 9-month-old who has been exposed to Hepatitis A in daycare that she should:
a. Get the hepatitis A vaccine now rather than waiting until the child is 1 year old b. Use airborne precautions in the home while caring for the baby c. Get passive immunity for the baby with immunoglobulin d. Treat the rash with calamine lotion