A patient who amputated his thumb in a lawnmower accident hands the ER nurse his thumb in a glass jar. The nurse should:
1. place the thumb in a baggie with iced Ringer's lactate.
2. wrap the thumb in plastic wrap and place on ice.
3. leave the thumb in the jar and put it in the refrigerator.
4. wrap the thumb in a cloth saturated with normal saline and place in a baggie.
4
The amputated part should be wrapped in a normal saline solution–soaked towel, placed in a baggie, and put in a cool bath.
PTS: 1 DIF: Cognitive Level: Analysis REF: 945
OBJ: 4 TOP: Care of the Amputated Thumb
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
# 19. Risk for injury related to unsteady gait is an appropriate nursing diagnosis for the above-knee amputee who is going home. The statement by the patient that indicates under-standing of the risk is:
1. "I will have my daughter get rid of my scatter rugs."
2. "I like to keep my newspapers on the floor in front of my chair."
3. "I don't need to practice using stairs because I will only go up and down a couple of times each day."
4. "Why would I need arm exercises? They operated on my leg."
1
Planning safety provisions indicates that the patient is aware of potential sources of injury.
PTS: 1 DIF: Cognitive Level: Application REF: 943
OBJ: 5 TOP: Risk for Injury
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment
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The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse's priority action related to this finding?
a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patient's chart.
The nurse is identifying nursing diagnoses for a patient's care. In which order should the nurse complete this process?
Choice 1. Draw conclusions about the present health status. Choice 2. Determine etiologies and categorize problems. Choice 3. Cluster cues and identify data gaps. Choice 4. Verify the problem or diagnoses. Choice 5. Identify significant cues.
Which statement is priority teaching at the time of discharge for the client who receives imipramine (Tofranil)?
1. "You will need to maintain a low-fat diet while on this medication." 2. "You must maintain a normal intake of salt while on this medication." 3. "Please notify your health care provider of any changes in urine quantity or quality." 4. "You can stop the medication when you are no longer feeling depressed."