A patient has just had a bone marrow biopsy taken from the iliac crest. What is the nurse's next action?
1. Apply a fluid collection device around the drain.
2. Cover the biopsy site with a bulky pressure dressing.
3. Plan to assess the patient regularly for pain and bleeding.
4. Have the patient ambulate to mobilize marrow replacement.
3
Rationale 1: A drain is not inserted in this procedure.
Rationale 2: There is no need to use a bulky dressing over this site. A small gauze square is applied with mild pressure.
Rationale 3: The nurse should assess this patient regularly for pain and bleeding.
Rationale 4: There is no specific need to have the patient ambulate.
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a. Listening to music on a headset b. Participating in biofeedback c. Playing video games d. Using guided imagery
The client is a heavy drinker. He is frequently in bar fights because every time he visits a tavern someone is "always picking a fight with me." He has been diagnosed with a paranoid personality disorder. He is also categorized as having a
1. dual diagnosis. 2. schizoid personality. 3. problem with fighting. 4. histrionic personality.
The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique?
a. Closing the patient's door to limit room traffic while preparing the sterile field b. Using clean procedure gloves to handle sterile equipment c. Placing the nonsterile syringes containing flush solution on the sterile field d. Remaining 6 inches away from the sterile field during the procedure
A client with heart failure develops an increase in preload. What pathophysiologic process is responsible for these changes?
A. A reduction in sympathetic stimulation B. Stimulation of coronary baroreceptors C. Activation of the renin-angiotension-aldosterone system D. Arterial vasodilation and subsequent increase in oxygen consumption