The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which of the following should the nurse do?
1. dress the wound as prescribed
2. cover the wound with a sterile dry dressing
3. assess for pain and warmth
4. encourage the patient to ingest more fluids
3
Rationale: The cardinal signs of an inflammation exist in a wound that is infected and include redness, edema, pain, and warmth. Since the patient's wound is demonstrating redness and edema, the nurse needs to assess for pain and warmth to aid in determining if the wound is inflamed and infected. The nurse should not just dress the wound as prescribed or cover the wound with a sterile dry dressing. Encouraging fluids is not going to reduce the inflammation that is occurring in the wound.
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The physician has ordered 140 mg of ampicillin for an infant to be administered intramuscularly (IM). The nurse reads the vial and determines that there is 0.25 kg in 5 mL. How many mL of medication will the nurse prepare?
1. 7 mL 2. 0.07 mL 3. 2.8 mL 4. 0.28 mL
The nurse prepares an older man who has OA for discharge. Which instruction does the nurse include in patient teaching to maintain safety for this man?
a. Take ibuprofen (Motrin) rather than opioid analgesics. b. Increase rest periods to slow disease pro-gression. c. Report joint instability to the health care provider. d. Avoid stretching the affected joint during exercise.
Because of low morale and a high level of territorialism, the unit personnel decided they wanted the administration to remove the new nurse manager. The unit personnel were exhibiting what type of behavior?
a. Performance problems b. Bullying behavior c. Attendance problems d. Healthy behavior
When a resident paces and wanders, you should
A) restrain the resident in a chair for safety. B) ask the nurse to calm the resident down. C) allow the resident to wander but monitor him. D) ask an alert resident to monitor the wanderer.