The nurse is caring for a patient having a bone marrow biopsy. What nursing action is the most important following the biopsy?
a. Observe for bleeding.
b. Encourage oral fluids.
c. Administer an analgesic for pain.
d. Monitor the puncture site for infection.
ANS: A
Following biopsy, the nurse observes the aspiration site for bleeding and infection. Because bleeding is the most immediately life-threatening, it takes first priority. B. C. Pain control and fluids are also important, but they are not the most immediately life threatening. D. Infection at the site will not occur immediately after the procedure.
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A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:
a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.
What information should be obtained from the patient before an iodine-131 test?
a. Presence of metal in the body b. Allergy to sulfa drugs c. Status of possible pregnancy d. Use of prescription drugs for hypertension
The nurse needs to apply a warm moist compress to an open draining wound. Place suitable nursing interventions for the compress in the proper order for moist heat application
1. Apply clean gloves. 2. Apply sterile gloves. 3. Add sterile gauze to basin. 4. Fill the basin with warm water. 5. Pour sterile solution into sterile basin. 6. Remove existing dressing and discard.
The postpartum homecare patient asks the nurse why the visit is taking place. Which response is best? "We make homecare visits to:
1. "Reinforce any teaching that you didn't quite grasp in the hospital." 2. "Verify that both you and the baby are safe and doing well." 3. "Provide a service that leads to better statistical outcomes." 4. "Thoroughly assess your baby to make sure he is growing."