A home care client with a leg wound is unable to climb stairs to the second floor, where the bathtub is located. Which is the nurse's best intervention?
a. "I'll show you how to use a syringe to cleanse the wound."
b. "It is not necessary to clean this wound because it is not infected."
c. "You can use the kitchen sink and clean tap water for this purpose."
d. "You will have to come to the hospital each day for hydrotherapy."
A
Mechanical débridement can be accomplished using the forceful ejection of tap water from a 35-mL syringe. Soaking in a tub is not essential. The client does not have to travel to the hospital.
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The nurse is charting using paper nursing notes. The nurse is aware that:
a. attorneys are not allowed access to medical records during litigation. b. when mistakes are made in documentation, the nurse should scribble out the entry. c. only one nurse should document on a sheet so that it can be removed in case of error. d. the medical record is the most reliable source of information in any legal action.
As an LVN/LPN, your role in the nursing process is to gather information and work with the patient. In carrying out this role, which of the following tasks can be delegated to you?
1. Interview the patient on admission. 2. Plan and evaluate the patient's care. 3. Check vital signs and medication response. 4. Carry out all steps of the nursing process.
Signs that precede labor include (choose all that apply):
a. Lightening. b. Exhaustion. c. Bloody show. d. Rupture of membranes. e. Decreased fetal movement.
Which serum sodium level should the nurse recognize as hyponatremia?
A. 137 mEq/mL B. 140 mEq/mL C. 133 mEq/mL D. 145 mEq/mL