A nurse is assessing a client who recently returned from a camping trip. The client is experiencing edema in the right foot. When assessing the foot, the nurse notes a sore and suspects cellulitis
Which further data will the nurse assess to support the suspicion?
A) BUN and creatinine
B) Breath sounds
C) Blood cultures
D) Redness, pain, and drainage at the site
Answer: D
Classic signs of cellulitis are swelling, pain, redness, and possibly drainage at the site. BUN, creatinine, and blood cultures are ordered by the physician and are not nursing assessments. Breath sounds are not indicated at present, as the infection is in the foot. Blood cultures are ordered by the physician and are not nursing assessments.
You might also like to view...
A hospital administrator initiated the emergency operations plan (EOP) after being notified that a tornado struck a nearby community
Thirty minutes later law enforcement calls to report that while significant damage was done, there were only minor injuries. What should the administrator do now? 1. Follow the EOP to deactivate the plan. 2. Let the plan continue for another hour to ensure that no victims arrive. 3. Call the emergency department and tell the staff that the plan is discontinued. 4. Notify local media that the EOP was discontinued.
A nurse assesses the lower extremities of an older adult and notes a small ulcer between the per-son's great toe and second toe
The ulcer has well-defined edges and there is no bleeding; however, there is a small amount of necrotic tissue present. This wound is most likely a(n): a. venous ulcer. b. arterial ulcer. c. pressure ulcer d. surgical wound.
Albuterol sulfate (Proventil) has a short half-life and duration of action. Based on this information, what should the nurse select as an appropriate dosing schedule for this drug?
a. Once a day b. Once every other day c. 3 or 4 times a day d. 2 times a day
A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents?
A. Reactions to stress are relative rather than absolute; individual responses to stress vary. B. It is abnormal for identical twins to react differently to similar stressors. C. Identical twins should share the same temperament and respond similarly to stress. D. Environmental influences weigh more heavily than genetic influences on reactions to stress.