The nurse is preparing to cleanse a pressure wound on a patient. Which of the following solutions are the nurse's best choices for cleansing the wound? Select all that apply
A) Hydrogen peroxide
B) Normal saline
C) Acetic acid
D) Provodone-iodine
E) Commercial wound cleansers
F) Dakin's solution
B, E
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The nurse is assessing the pain intensity of a client who does not speak the same language fluently. The most useful tool for the nurse in this situation is:
1. A 10-point pain intensity scale. 2. The Wong/Baker Faces rating scale. 3. Use of figure drawings. 4. Determining the pattern of pain.
After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea. The nurse is concerned that pneumothorax may be occurring. Which assessment findings would support this concern?
1. Restlessness 2. Chest pain 3. Decrease in pulse oximetry reading 4. Severe headache 5. Combativeness
The nurse uses a common nursing diagnosis for patients with disorders of the hematologic system, which is:
1. Impaired Tissue Integrity. 2. Disturbed Body Image. 3. Ineffective Tissue Perfusion. 4. Activity Intolerance.
A mother brings her two-year-old child to the pediatric office for a sick visit. The child is seen regularly at the office and was last seen at her well-child visit two months ago
Based on this information, which is the most appropriate action by the nurse? 1. Asking the mother to leave the room after obtaining the history 2. Obtaining a comprehensive history, including sociodemographic data 3. Focusing exclusively on the reported illness 4. Reviewing health promotion and maintenance activities