You suspect that your client is hemorrhaging internally. For suspected internal hemorrhage, you would assess for:
1. bloody drainage on dressing, distention of the affected area, and a change in the amount or type of drainage from a drain.
2. distention of the affected area, a change in the amount or type of drainage from a drain, and signs and symptoms of hypovolemic shock.
3. bloody drainage on dressing and signs and symptoms of hypovolemic shock.
4. bloody drainage on dressing, on areas around the dressing, and posterior to the wound site.
ANS: 2
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The parents demonstrate that they have understood the nurse's teaching with regard to colostomy stoma care for their infant if they state:
1. "We will change the colostomy bag with each wet diaper.". 2. "We will use adhesive enhancers when we change the bag.". 3. "We will watch for skin irritation around the stoma.". 4. "We will expect a small amount of bleeding after cleansing the area around the stoma.".
Perimenopause is a phase in a woman's life when:
A) The menses have ceased. B) The body is transitioning to ovarian follicular failure. C) Women have drastic symptoms they find difficult to live with. D) They have no symptoms related to hormone changes.
The nurse is preparing to administer a medication and reviews the patient's chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The nurse's actions are reflective of which phase of the nursing process?
a. Assessment b. Evaluation c. Implementation d. Planning
A nurse is preparing a medication administration record (MAR) at the healthcare facility. The nurse documents the client's name, medication name, dosage, administration route, and scheduled times in the MAR
Which is the most accurate way to verify accuracy of the MAR? A) Check with the client to see if he or she has been administered the medication. B) Perform an order sheet check just before medication administration. C) Record the trade name of the medication to promote accuracy. D) Compare the medication record with the original physician's order.