A client has been admitted for vacuum-assisted wound closure (VAC) treatment for a chronic leg wound
The client's past medical history includes atrial fibrillation and stroke, and medications include warfarin sodium (Coumadin) and sotolol (Betapace). Which action by the nurse is most appropriate? a. Place the client on continuous telemetry monitoring.
b. Call the health care provider with this in-formation.
c. Let the wound care nurse know that the client has arrived.
d. Order the VAC and gather other needed supplies.
B
A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding com-plications. The health care provider needs this information quickly to plan other therapy for the client's wound.
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When an LP/VN is delegating or assigning the accomplishment of a specific task, which of these factors should be considered FIRST?
a. Should this task be delegated for a specific client? b. Is this the appropriate client setting for this task to be performed? c. Are there sufficient resources available for this task to be performed? d. Can the task be clearly described to the assigned personnel?
Delayed capillary refill may alert you to:
a. hypovolemic shock. b. moderate hypoxemia. c. subnormal intracranial pressure. d. upper respiratory infection.
A female client has had a type 1 female circumcision. The nurse realizes that which of the following has been surgically removed on the client?
1. Clitoris 2. Clitoris and labia minora 3. Clitoris, labia minora, inner surface of labia majora, and suturing of the vagina 4. Clitoris and uterus
A home health nurse is admitting a 54-year-old man for services following a coronary artery bypass graft (CABG). As part of the initial visit the nurse completes a family assessment. What is the purpose of this nursing action?
a. Allows for health promotion and disease prevention appraisal b. Allows for inclusion of family members in decision-making c. Allows for data collection necessary for comparison to Healthy People 2020 d. Allows for development of patient-centered care