Which is the appropriate initial intervention for the nursing diagnostic statement Impaired skin integrity related to poor wound healing?
a. Reinforce the wound dressing as needed with 4 x 4 gauze.
b. Perform the ordered dressing change twice daily.
c. Document wound characteristics.
d. Assess wound appearance each shift.
D
The most appropriate initial intervention is to assess the wound. Assessment guides the type and order of other interventions. The nurse must assess the wound first before the findings can be documented.
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The nurse is teaching a parent of an infant to limit the amount of formula to encourage the intake of iron-rich food. What amount should the nurse teach to the parent?
a. 500 ml b. 750 ml c. 1000 ml d. 1250 ml
During the assessment of a client, the nurse becomes concerned that the client is at risk for suicide. Which of the following assessment findings would support the nurse's conclusion? (Select all that apply.)
1. Alcohol use 2. Use of illegal substances most days of the week 3. Recent death of spouse 4. Laid off from employment 6 months ago 5. Weather preventing the planting of an annual garden 6. Family scheduled to visit in a few weeks
A patient who has been taking efavirenz (Sustiva) reports a sore throat, fever, and blisters. What is the nurse's best action?
a. Hold the dose and notify the prescriber. b. Document the report as the only action. c. Remind the patient that these are symptoms of opportunistic infection. d. Reassure the patient that these are common and expected side effects of the drug.
Which of the following pain interventions is appropriate for a 5-year-old, post-op patient?
1. To provide comfort and decrease pain, use a combination of medications, positioning, distraction, and family involvement 2. Assess for pain using a developmentally appropriate pain scale 3. Evaluate the efficacy of all the pain control interventions 4. All of the above