The nurse assesses the transparent film dressing of the client and observes white opaque exudate and reddened and edematous wound edges. Which is the priority intervention for the nurse to implement?
1. Record the observation.
2. Remove white exudate.
3. Obtain a wound culture.
4. Apply absorbent dressing.
3
3. The nurse suspects an infected wound because exudate can indicate wound debris from an infection; so, the nurse obtains a wound culture to identify the pathogen. The provider can initiate empirical treatment while the microorganisms grow in the cul-ture; however, the nurse is careful to obtain the culture before antimicrobial therapy begins.
1. The nurse records the wound assessment after completing wound care and obtain-ing the culture.
2 and 4. Before applying another dressing, the nurse cleanses the wound bed to re-move the exudate. If the wound is infected, the exudate will accumulate again neces-sitating the use of an absorbent dressing to promote wound healing.
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A 54-year-old African American man has presented for a follow-up appointment shortly after being diagnosed with hypertension and being placed on an angiotensin-converting enzyme (ACE) inhibitor
The nurse takes the patient's vital signs at the beginning of the appointment and obtains a blood pressure of 177/96 mm Hg. What factor should the nurse consider in light of the patient's sustained high blood pressure? A) The patient's culture may not prioritize taking a medication on a regular basis. B) Biologic variations may be influencing the effectiveness of the medication. C) The patient's culture may not acknowledge "symptom-free" problems such as blood pressure. D) The patient's diet may be negatively affecting the effectiveness of the medication.
The nurse sees a pattern on the fetal monitor that looks similar to early decelerations, but the deceleration begins near the acme of the contraction and continues well beyond the end of the contraction
Which nursing action indicates the proper evaluation of this situation? a. Continue to monitor these early decelerations, which occur as the fetal head is compressed during a contraction. b. This deceleration pattern is associated with uteroplacental insufficiency, so the nurse acts quickly to improve placental blood flow and fetal oxygen supply. c. This pattern reflects variable decelerations. No interventions are necessary at this time. d. Document this reassuring fetal heart rate pattern but decrease the rate of the intravenous fluid.
A 6-year-old is admitted to the emergency department after being rescued from a pond. The child fell through the ice while ice skating. What can a nurse expect when rewarming a hypothermic patient?
A) To assess oral temperature frequently B) To provide continuous ECG monitoring C) To administer unwarmed oxygen D) To find a strong pulse
A postmenopausal patient who has had a hysterectomy and who has a family history of coronary heart disease reports experiencing vaginal dryness and pain with intercourse but tells the nurse that she doesn't want to take hormones because she is
afraid of adverse effects. The nurse will suggest that the woman ask her provider about: a. Depo Provera. b. Estraderm. c. low-dose estrogens. d. Premarin vaginal.