The nurse is monitoring for bleeding in a child following surgery for removal of a brain tumor. The nurse checks the head dressing and notes the presence of dried blood on the back of the dressing
The child is alert and oriented, and the vital signs and neurological signs are stable. Which of the following nursing actions would be most appropriate initially? 1. Change the dressing.
2. Document the findings.
3. Recheck the dressing in 1 hour.
4. Check the operative record to determine whether a drain is in place.
4
Rationale: The initial nursing action is to determine whether a drain is in place because this could attribute to the drainage seen on the dressing. The nurse would not change the dressing without a physician's prescription. Rechecking the dressing is an appropriate action, but it is not the initial action. The findings would be documented, but the initial action would be to assess the cause of the drainage further.
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The nurse is planning to teach a woman about perimenopause. What would the nurse include regarding lowered estrogen level?
a. It prevent osteoporosis. b. It decreases vaginal lubrication. c. It raises the level of low-density lipoproteins. d. It raises the level of high-density lipoproteins.
Young adulthood is a time in which an individual:
1. earns most of his or her money, pays most of the taxes, and has most of the power in business. 2. settles down to jobs, raises a family, and take on new responsibilities. 3. experiences personal freedom and enjoys maximum influence over others. 4. focuses on many adjustments that must be made to physiologic, psychological, and social changes.
Before beginning to perform a gynecological assessment on a woman, you would ask the patient to:
A) Take short, quick breaths to lessen the discomfort. B) Assume the supine position. C) Empty her bladder. D) Review the medical history.
The nurse is caring for a patient diagnosed with uncontrolled asthma. The nurse realizes that this diagnosis will affect which element of the patient's pulmonary gas exchange?
1. diffusion 2. perfusion 3. ventilation 4. removal