A postoperative patient visits the ambulatory care clinic complaining of just "not feeling well." The patient has an elevated temperature. Which assessment finding should indicate to the nurse that the wound has become infected?
a. Negative culture
b. No odor
c. Presence of fluid around the edges
d. Purulent drainage coming from the incision area
D
Purulent drainage indicates an infection as it contains dead or living organisms and white blood cells and is often yellow, green, or brown. If the drainage has a pungent or strong odor, an infection is likely. No odor indicates normal healing. When an infection develops, the wound edges are usually brightly inflamed, warm, tender, and swollen. Culture results would come back positive for bacteria if an infection is present; a negative culture indicates no infection is present.
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An older adult patient experienced a fall during the previous night shift, and the care team suspects that the patient may be experiencing orthostatic hypotension
When assessing this patient for postural changes in blood pressure (BP), the nurse should: A) Record the patient's standing, sitting and lying BPs in prompt succession while assisting the patient in transitions B) Ask the patient to begin by adopting the position that most often causes him or her to feel dizzy then assess BP in a variety of positions C) Take BP readings when the patient is lying, sitting, and standing with a minimum period of 30 minutes between each measurement D) Assess the patient's BP in supine, feet dangling, and then standing positions with 1 to 3 minutes of waiting between each reading.
The nurse is cleaning the patient with fecal incontinence when he says, "This is so embarrassing, and it makes me really angry." The nurse's best response would be:
1. "Don't worry about it, it's my job to clean you up." 2. "You should have called me sooner and this wouldn't have happened." 3. "Do you feel angry and embarrassed?" 4. "Would you rather let your family clean you up?"
Which would be most valuable to include on a list of references?
a. People who have worked in the agency to which one is applying b. Personal friends who can be trusted to provide a positive reference c. Influential people in the community d. Health care workers who have supervised one's work and are willing to provide a reference
A patient's call light goes unanswered. The person's son finds the patient lying on sheets soaked with urine. This is:
a. Neglect b. Emotional abuse c. Physical abuse d. Malpractice