The nurse is caring for a patient with skeletal pins that have been placed for traction. What does the nurse expect to see in the first 48 hours?
a) Clear fluid drainage weeping from the pin insertion site
b) Some bloody drainage, but very minimal
c) Swelling at the site with tenderness to gentle touch
d)Dressings around the pin sites to be dry and intact
Answer: a) Clear fluid drainage weeping from the pin insertion site
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Which situation is an example of reverse delegation?
1. The nurse manager asks the staff nurse to attend an in-service on a new product. 2. The nursing supervisor asks the nurse manager to attend a meeting with the physicians. 3. The licensed practical nurse asks the nurse manager to administer insulin to her client. 4. The staff nurse asks the licensed practical nurse to record intake and output in his client's charts.
A patient who is being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. What does the nurse realize is the most likely reason?
1. The patient is developing hypersensitivity to the medication. 2. The patient is reacting positively to the medication. 3. The patient needs an increase in dosage of the medication. 4. The patient is not responding to the medication.
When using an antibiotic skin product that contains neomycin, the nurse should monitor the client for:
a. hypersensitivity response. c. hepatotoxicity. b. nephrotoxicity. d. ototoxicity.
The nurse is preparing adult smoking cessation material for a patient admitted with heart failure. What criteria did the nurse use to determine that the patient should receive this material?
1. Patient smoked cigarettes any time during the last year prior to hospitalization 2. Patient uses chewing tobacco 3. Patient smokes five cigars a week 4. Patient stopped smoking five years prior to hospitalization