A nurse assesses for signs of infected phlebitis. How should the nurse most accurately describe this complication when documenting?
a. Rupture of the cannula with a lump under the skin
b. Pale, cool skin with swelling at the punc-ture site
c. Firm, cool, raised, painful area at the puncture site; oozing and purulent drai-nage
d. Puncture site red, warm, with an oozing drainage
D
Infection causes redness, warmth, and drainage from the intravenous site. Red streaks following the path of the vein may be visible.
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You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that elderly patients are frequently more anxious prior to surgery than younger patients. What would you increase with this patient to decrease her anxiety?
A) Analgesia B) Therapeutic touch C) Preoperative medication D) Sleeping medication the night before surgery
The nurse is administering a tuberculin skin test for a client. What is the nurse's understanding of the hypersensitivity response associated with this test? Select all that apply.
A) The test causes a release of lymphokines, which attract macrophages. B) Macrophages release lysozymes, resulting in local tissue damage. C) The antigen-presenting cell encounters a cytotoxic T-cell. D) Antigens invade the body and bind to antibodies in circulation. E) Antigen-antibody complexes activate complement.
The nurse prepares to take vital signs for a patient experiencing mani
a. What is the nurse's best intervention when the patient's talking interferes with the assessment? a. Use a voice volume louder than the patient's to say, "Stop talking now." b. Interrupt by saying, "It's time to take your vital signs now." c. Delay taking the vital signs until the patient is quieter. d. Wait tolerantly for the patient to finish talking.
A nursing intervention that will be planned to occur early in the nurse-patient relationship with a patient with an eating disorder is:
a. Using confrontation to attack denial b. Placing the patient in a therapeutic group c. Formulating a therapeutic nurse-patient alliance d. Attacking enmeshment by separating patient and family