A nurse is evaluating the epidural catheter insertion site and suspects that the intraspinal catheter has punctured the dura when _____ noted
a. clear drainage is
b. bloody drainage is
c. purulent drainage is
d. redness, warmth, and swelling are
A
Clear drainage may indicate puncture of the dura. Bloody drainage may indicate that the catheter has entered the blood vessel. Purulent drainage is a sign of infection. Redness, warmth, and swelling are signs of inflammation. Local inflammation and superficial skin infection can occur at the insertion site.
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The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon?
a. The patient has bowel sounds x 4 quadrants and is passing gas. b. The patient has no nausea, and abdominal pain is minimal. c. The patient feels hungry for chicken soup and hot tea. d. The patient's nasogastric tube was discontinued the previous day.
As you perform the iliopsoas muscle test on a patient with acute abdominal pain, the patient complains of pain in the right lower quadrant as you place your left hand over his right thigh and
a. press upward with your right hand under his thigh as he raises his leg. b. gently jab his abdomen with a pin. c. press downward on his right thigh as he raises his leg, flexing at the hip. d. flex his leg at the hip and knee with your right hand under his lower leg.
The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which of the following nursing interventions would be appropriate?
1. Assess fundus and bladder status. 2. Catheterize the client. 3. Administer Methergine IM per order. 4. Contact the physician immediately.
The nurse has provided care to a patient according to the concept of wellness. Which outcome indicates that care has been successful for this patient?
1. The patient is returning home with adjustments in the home environment to support a temporary alteration in mobility status. 2. The patient needs additional teaching to understand the reason for taking Coumadin at the same time every day. 3. The patient is not independent with personal care and will need assistance when at home. 4. The patient is easily fatigued and will need assistance with meal preparation and medication administration.