The nurse assesses the patient's transparent film dressing and observes white opaque exudate and reddened and edematous wound edges. Which is the priority intervention for the nurse to imple-ment?
a. Record the observation in the patient's record.
b. Remove the white exudate carefully.
c. Obtain an order for a wound culture.
d. Apply a light absorbent dressing.
C
The nurse suspects an infected wound because exudate can indicate wound debris from an infec-tion. Although all of these implementations may be performed, the priority is to start effective treatement for the suspected infection, so the culutre must be obtained as soon as possible. The nurse notifies the healthcare provider so an order can be written for the culture then obtains a wound specimen sample for testing. The nurse must obtain the culture before antimicrobial ther-apy begins. The wound assessment is recorded after completing wound care and obtaining the culture.
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Conjunctivitis in the newborn is the most commonly seen eye infection seen with which STI?
A) Genital herpes B) Hepatitis B C) Syphilis D) Chlamydia
The nurse is preparing teaching for the parents of a newborn with a newly placed ventriculoperitoneal shunt. What should the nurse include in this teaching? (Select all that apply.)
A) Restrict the intake of fruit, vegetables, and fluid. B) Expect to have the shunt replaced as the child grows. C) Examine the site every day for signs of swelling or redness. D) Notify the health care provider if the child develops a fever. E) Observe the child for signs of increased intracranial pressure.
Which stage of grief usually resolves after approximately 2 weeks?
a. Disorientation b. Shock and numbness c. Reorganization d. Searching and yearning
A nurse is working with a young male client who says that he is Elvis Presley. Recognizing that this is a delusion of grandiosity, the nurse decides that a goal today will be to promote a sense of self-worth and increased self-esteem
What did the nurse do? A) Reminded the client that his name is not Elvis and remarked on the qualities of his real name. B) Tell the client how handsome he looked and remarked on his classy sideburns. C) Complimented the client when he was being considerate of another, older patient on the unit. D) Asked the client to sing for the others on the unit to demonstrate his Elvis style.