A patient with a chronic heart valve problem is experiencing edema caused by deoxygenated blood in the veins of the lower extremities. A nurse should monitor the patient closely for the development of a
1. Sinus tract.
2. Stasis ulcer.
3. Pressure ulcer.
4. Contusion.
ANS: 2
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The nurse working on an acute pediatric unit is caring for an 8-year-old child who is profoundly mentally retarded with significant developmental delays and cerebral palsy that limits the child to a wheelchair
The child was admitted for a significant scoliosis, and has had surgery to fuse the spine, with insertion of rods on both sides of the spinal column. In addition to preventing infection and pain management, the nurse's priority of care is: 1. Careful movement and repositioning of the client. 2. Supporting family coping measures. 3. Providing respite care for the primary caregiver. 4. Encouraging ambulation as soon as possible.
The patient scheduled for a Syme amputation in the morning is concerned about the ability to stand on the amputated extremity. The patient asks the nurse about his ability to stand after surgery. What is the nurse's best response to this question?
A) "You will be able to withstand full weight-bearing on this durable extremity after the amputation." B) "You will have minimal weight-bearing on this extremity and will require the use of an assistive device." C) "You will not be able to use this extremity and will receive teaching on use of a wheelchair." D) "You will be fitted for a prosthesis and your commitment to rehabilitation will determine your functional abilities."
The physician has suggested that the client try Pepto-Bismol to relieve the diarrhea. The nurse might provide the following information:
A) "The Pepto-Bismol will turn your stools yellow." B) "Do not take the Pepto-Bismol for longer than 48 hours." C) "Take the Pepto-Bismol once per day." D) "Take the Pepto-Bismol before meals and at bedtime."
When deciding whether and when a task should be completed, a nurse must:
a. complete all tasks as they are thought of to prevent having to take time to consider which is most important. b. procrastinate and hope that someone will volunteer to do it. c. ask, "What will happen if I don't complete the task now?" d. view large projects holistically and not as many small pieces.