The nurse removes the patient's hydrocolloid dressing and observes minimal clear, watery drainage. Which action should the nurse take at this time?
a. Evaluate for leukocytosis.
b. Change to foam dressing.
c. Collaborate with the healthcare provider.
d. Document serous drainage.
D
The nurse documents that there is serous drainage after the dressing change to record the wound drainage accurately. Serous drainage is a benign finding. Leukocytosis indicates infection, in-flammation, or malignancy. If the patient has leukocytosis, the nurse determines that the wound is probably not the cause because serous drainage is a benign finding and inconsistent with clin-ical indicators of infection. The nurse uses a dressing indicated for wounds with minimal exudate and does not need to collaborate with the healthcare provider because serous drainage from the wound is consistent with a successful wound care protocol.
You might also like to view...
Which of the following is a state of mind, a specific place, freedom from intrusion, or control over the exposure of self or of personal information?
1. Privacy 2. Confidentiality 3. Security 4. HIPAA
A patient tells the nurse that after eating some food that tasted "off" he experienced a severe stomachache. However, after a few hours the discomfort was gone and he felt fine. Which information should the nurse consider when formulating a response to this report?
1. Decreased production of mucous in the duodenum likely propelled the organism through the system in a few hours. 2. The duodenal pH of 4.0 killed the offending organism. 3. The acidic stomach environment likely killed any offending organisms in the ingested food. 4. Chyme blocked the offending organism from attaching to the walls of the GI tract.
A young female client with cystic fibrosis (CF) wishes to become pregnant but is concerned about the effect of CF on fertility. The nurse bases a response with the understanding that
a. breastfeeding will not be possible because of plugged milk glands. b. only about 20% of women with CF are infertile. c. pregnancy carries a high risk of spontaneous abortion (miscarriage). d. women with CF are unlikely to become pregnant.
The nurse is caring for a 4-year-old child who is receiving 2 L of oxygen per nasal cannula. What disadvantage should the nurse consider when planning care for the child?
a. The child may need to have high humidity administered with the oxygen. b. The child may not be able to eat and drink comfortably. c. A nasal cannula may cause an accumulation of moisture on the face. d. A nasal cannula may cause abdominal distention.