The nurse caring for a patient who is two days post hip replacement notifies the physician that the patient's incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor
What type of problem is the nurse dealing with?
A) Collaborative problem
B) Nursing problem
C) Medical problem
D) Administrative problem
Ans: A
Feedback:
In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The other answers are incorrect because the signs and symptoms of infection are a medical complication that requires interventions by the nurse.
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The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea
What is the first action the nurse should take? a. Review and implement the primary care provider's prescriptions for treatments. b. Perform a quick physical examination of breathing, circulation, and oxygenation. c. Gather a thorough medical history, including current symptoms, from the family. d. Administer oxygen to the patient through a nasal cannula.
A client is being treated with blood transfusions for a large peptic ulcer in the duodenum. Which information in the client's history should the nurse suspect as causing this health problem?
A) Allergies to penicillin and morphine sulfate B) History of chronic atrial fibrillation C) Daily medications include naproxen sodium and warfarin (Coumadin). D) Six weeks postoperative cataract extraction with lens implant
A client has been admitted to the emergency department with a head injury that has required the insertion of an artificial oral airway. What is the primary purpose of this intervention?
A) To prevent aspiration of saliva or secretions B) To prevent the client's tongue from obstructing the airway C) To bypass the nasal portion of the client's airway D) To prevent injury to the client's oral mucosa
An elderly patient does not complain of thirst. What should the nurse do to assess that this patient is not dehydrated?
1. Ask the physician for an order to begin intravenous fluid replacement. 2. Ask the physician to order a chest x-ray. 3. Monitor serum osmolality level. 4. Ask the physician for an order for a brain scan.