The nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks. Which complication does the nurse document and report?
a. Diverticulitis
b. Stress diarrhea
c. Curling's ulcer
d. Perforated bowel
ANS: C
Curling's ulcer is a complication of burn victims resulting from the stress of their trauma.
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A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8 ° F (37.6 ° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take?
a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the client's intravenous fluid replacement rate. d. Check the client's blood glucose and administer orange juice.
The relationships among nursing, patients, health, and the environment are the basis for:
a. care plans. b. nursing models. c. physician's orders. d. evaluation of patient care.
The patient's sacrum has nonblanching redness on Monday. On Wednesday the nurse determines that the pressure ulcer on the patient's sacrum is stage II despite skin care, including an air-filled mattress overlay
Which is the best nursing intervention to implement? a. Document the extreme progression of the patient's pressure ulcer. b. Collaborate with the healthcare provider for physical therapy. c. Reassess the patient's need for a different support surface or bed. d. Increase the frequency of bathing and li-nen changes as needed.
The nurse teaches the client hand washing before discharge and asks for a return demonstration. Which client behavior indicates that the client is ready for discharge?
1. Washes hands with running water 2. Washes hands with soap and water 3. Washes hands with very hot water 4. Washes hands in warm, soapy basin