The patient has experienced large epidermal skin sloughing from a medication reaction. The dermal levels of the skin are exposed for over 40% of the patient's body. What is the most serious adverse reaction that the nurse should expect?
A) Excess fluid volume loss
B) Elevated body temperature
C) Numbness and paresthesia
D) Disturbance of body image
A
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Which postoperative sign should a nurse report immediately when caring for a patient with an endarterectomy with a synthetic graft?
a. Headache b. Fever c. Edema d. Pain
A nurse is counseling a client following an unexpected loss. If given adequate support and adap-tation, which of the following best describes what will happen with the client?
a. Recover from the crisis and become men-tally ill b. Avoid the loss and potential mental illness c. Be able to ignore the grief d. Resume previous lifestyle in spite of sad-ness
The nurse is teaching the patient how to size the skin barrier around the stoma. Which instruc-tions does the nurse include?
a. Use the measurement guide for a proper fit. b. Extend the skin barrier to cover the inci-sional area. c. Make a wick from toilet tissue before changing the skin barrier. d. Trim the skin barrier to fit slightly over the stoma margin.
When a nurse decides to delegate a nursing task to others, a number of considerations take place before the decision itself is made. Which of the following is not one of these considerations?
a. needs of the patient b. condition of the patient c. potential harm d. status of the staff