A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?
A) "We can put him in the tub to bathe him once the cord falls off and is healed."
B) "The cord stump should change from brown to yellow."
C) "Exposing the stump to the air helps it to dry."
D) "We need to call the doctor if we notice a funny odor."
B
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The nurse reviewing the physician's diagnosis for a patient who has sustained a basal skull fracture knows that the patient should be observed for:
A) An area of bruising over the mastoid bone B) Bleeding from the ears C) An increase in pulse D) Difficulty sleeping
Which nursing diagnosis has the highest priority for a patient with an acute head injury?
A) Deficient fluid volume B) Ineffective tissue perfusion: cerebral C) Risk for infection D) Ineffective airway clearance
A home health nurse is making a visit to a new patient. During the visit, the patient's husband arrives home in an intoxicated condition. He speaks to both you and the patient in an abusive and threatening manner
What should you do? A) Ignore the husband and focus on the patient B) Return to your agency and notify your supervisor C) Call the police from your cell phone D) Remove the patient from the home
At 6 weeks after bone marrow transplantation, a nurse observe that the client has rising white blood cell, erythrocyte, and platelet counts. What is the nurse's interpretation of these find-ings?
A. The transplant has engrafted. B. The client has a systemic infection. C. The leukemia is no longer in remission. D. The client has graft-versus-host disease.