A nurse is assessing the wound in the right hip of a client following surgery. The wound has clean edges. How should the nurse document the wound in the electronic medical record?
A) Incision
B) Abrasion
C) Laceration
D) Puncture
A
Feedback:
An incision is a wound with clean edges. A wound with torn, ragged edges should be documented as a laceration. Abrasion is the rubbing off of the skin's surface. A puncture is a deep stab wound.
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The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first?
A) Feel for the fetal buttocks or head while palpating the abdomen. B) Feel for the fetal back and limbs as the hands move laterally on the abdomen. C) Palpate for the presenting part in the area just above the symphysis pubis. D) Determine flexion by pressing downward toward the symphysis pubis.
Which statement made by the client with peripheral arterial disease concerning positioning of edematous lower extremities requires further clarification?
A. "I may sleep with my affected leg hanging from the bed." B. "I will elevate my legs above the level of my heart." C. "I can sit upright in a chair for comfort." D. "I will avoid crossing my legs."
The nurse is caring for a small child who puts his arm through the side rail just as the nurse is lowering the side rail. The child gets a big bruise. The housekeeper asks the nurse what happened. The nurse should:
a. tell the housekeeper, since the housekeeper is part of the health care team b. restrict information to general statements such as, "It was an accident." c. suggest the housekeeper ask the head nurse d. avoid discussing the accident with the housekeeper
An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my energy to care for my mother
She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.