The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important?
a. Assess vital signs.
b. Don a mask and gown.
c. Gather needed supplies.
d. Perform hand hygiene.
ANS: D
To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.
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When the nurse performs the confrontation test, the nurse has assessed:
a. Extraocular eye muscles (EOMs). b. Pupils (pupils equal, round, reactive to light, and accommodation [PERRLA]). c. Near vision. d. Visual fields.
The nurse is preparing to admit a client who is experiencing alcohol withdrawal. The nurse should prepare the room by:
1. instituting seizure precautions. 2. assessing vital signs every 8 hours. 3. providing nutritious meals. 4. providing skin care.
A 69-year-old man is postoperative day 2 following a transurethral prostatic resection (TUPR)
The patient had his urinary catheter removed at 06:00 this morning but has not voided in the 5 hours since the removal, despite the fact that he has been drinking large amounts of fluids. What nursing assessment will most accurately determine whether the patient is retaining urine? A) Bladder palpation B) Bladder ultrasound C) Inspection of the patient's pubic region D) An audit of the patient's recent intake and output
Proprioception should be assessed while the patient is:
a. prone. b. supine. c. seated. d. standing.