A day 1 post op patient has the following abnormal assessment findings: pain 7/10, diminished lung sounds, hypoactive bowel sounds, and a saturated bloody abdominal dressing and bedsheets. Which would be the nursing priority?
A. Pain
B. lung sounds
C. bowel sounds
D. wound care
Answer: D. wound care
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The nurse does not know the answer to a question posed by a client. Which of these actions should the nurse take?
a. Admit not knowing but offer to find out. b. Give the client literature pertaining to the subject. c. Suggest the client ask the health care provider. d. Tell the client what a possibly correct answer may be.
A client tells the nurse that he receives health care services through the private sector. This sector of the health care delivery system includes:
a. independent providers who are reimbursed on a fee-for-service basis. b. providing public school nurse services. c. providing health care to the homeless population. d. Medicaid services.
The nurse is assessing the vital signs of an elderly client and obtains a temperature of 97.1 degrees Fahrenheit. Which of the following actions is most appropriate?
1. Document the finding as normal. 2. Encourage the client to drink warm fluids. 3. Request to turn up the client's thermostat. 4. Apply warmed blankets to the client.
The following are data from a client. Which is an example of subjective data?
a. The client reports having nausea. b. The client's blood pressure is 120/82 mm Hg. c. The client has a reddened area on the but-tocks. d. The client's blood sugar is 100 g/dl.