The "mustache" dressing of a client postoperative from a transsphenoidal hypophysectomy is saturated with clear, yellow-tinged fluid. What is the nurse's best first action?
A. Document the finding as the only action.
B. Obtain a specimen for culture.
C. Test the drainage for glucose.
D. Notify the physician.
C
Clear, yellow-tinged drainage could be serous or could contain cerebrospinal fluid (CSF). CSF contains a relatively high concentration of glucose; serous drainage does not.
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Mrs. Maguire, an 88-year-old woman, recently returned home to Texas after visiting her grandchildren in New York, Florida, and Connecticut. She comes into the office complaining of muscle pain, fever, headache, and extreme malaise
While talking with her, you find that she spent much time outdoors watching different sports and that the mosquitoes were very troublesome. In presenting this to the physician, you voice your concern that Mrs. Maguire may have a. TB—she has a headache and fever b. Dementia—how troublesome could mosquitoes be? c. West Nile virus—a mosquito could have bitten Mrs. Maguire d. Depression—she misses her family
A client who reports moderate to severe anxiety requires intervention. Which of the following teaching points would be helpful in assisting this client in the management of anxiety? Select all that apply
A) Using rapid respirations B) Taking cool shower or bath C) Visualizing a relaxing place D) Listen to music E) Smoke a cigarette F) Progressively tighten muscles
A patient, identified as a potential organ donor, has been diagnosed as brain dead and is being maintained on ventilator support. The nurse is reviewing the patient's hemodynamic parameters and is concerned about which findings?
1. Mean arterial pressure 50 mm Hg 2. Central venous pressure 5 mm Hg 3. Serum sodium 145 mEq/L 4. Serum glucose 140 mg/dL 5. Ejection fraction 30%
The home health nurse's instruction to the parents on the care of hemarthrosis in a child with hemophilia A would include: (Select all that apply.)
a. Resting the joint b. Elevating the limb c. Applying ice to the joint d. Compression or splinting e. Administration of aspirin