When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?
A) Deep red, fleshy-smelling lochia
B) Voiding of 350 cc
C) Heart rate of 120 beats/minute
D) Profuse sweating
C
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A partial-thickness burn is classified as either superficial or deep partial thickness, depending on how much dermis is damaged
Indicate whether the statement is true or false
What nursing consideration is important when suctioning a young child who has had heart surgery?
a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Expect symptoms of respiratory distress when suctioning. d. Administer supplemental oxygen before and after suctioning.
A patient admitted with an infected below-the-knee amputation (BKA) and heart failure (HF) is taking vancomycin (Vancocin) and furosemide (Lasix). Which of the following is the most important instruction the nurse should provide?
a. Report any ringing in the ears or dizziness. b. Report frequent nocturia. c. Elevate the affected extremity. d. Keep the head of the bed at 30 degrees.
A patient has difficulty sleeping well. The patient says, "I wake up a lot during the night and feel tired when I get up in the morning." Which finding best indicates that interventions to improve sleep were effective?
1. The patient is compliant with self-administration of hypnotic medications. 2. The patient has not experienced any falls or injuries. 3. The patient verbalizes an understanding of the causes of insomnia. 4. The patient reports an increased sense of feeling rested.