What is the priority nursing diagnosis for the client under general anesthesia during surgery?
A. Acute Pain related to surgical procedure
B. Risk for Infection related to surgical wound
C. Risk for Impaired Skin Integrity related to prolonged static position
D. Disturbed Body Image related to presence of surgical wound or scar
C
The problem that nursing is most responsible for with this client is ensuring maintenance of skin integrity.
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The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. What type of pain is this patient experiencing?
a. Visceral pain b. Somatic pain c. Radiating pain d. Referred pain
The nurse is assessing the printout from the fetal monitor. The nurse is legally responsible for:
a. recognizing deviations and taking appropriate action to prevent harm to the fetus. b. recognizing deviations and notifying the physician. c. recognizing and documenting deviations. d. providing technical assessment.
A 60-year-old woman has begun a course of oral antibiotics for the treatment of a urinary tract infection (UTI). The patient's nurse should recognize that the causative microorganisms most likely originated from:
A) Fecal contamination from the patient's perineum B) Colonization of the patient's urethra from bloodborne pathogens C) Proliferation of normal microbiotic flora D) Ingested microorganisms
The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture, with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?
1. Assess the odor of the amniotic fluid. 2. Perform Leopold's maneuvers. 3. Obtain an order for pain medication. 4. Complete a sterile vaginal exam.