The nurse assessing a patient 20 minutes after a bone marrow biopsy is concerned when the patient says:
1. "There is fresh blood on my dressing."
2. "I am thirsty."
3. "My hip feels bruised where they stuck the needle."
4. "I had a sharp pain in my leg when they pulled the needle out."
1
Fresh blood on the pressure dressing 20 minutes after the aspiration needs to be addressed. Usually, redressing with a pressure dressing and an ice pack are sufficient. Feelings of bruising and pain on extraction are to be expected. Thirst is of no clinical significance.
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To provide a safe environment for the patient, the nurse should be diligent in:
a. keeping a light on at night to prevent falls. b. hand hygiene between patient contacts. c. regulating the temperature to avoid drafts. d. changing the bed linen to diminish microorganisms.
A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client?
A) Briefly leave the client in order to call the primary physician to assess the client's condition. B) Order x-rays or CT scans for the client, as needed. C) Document the incident, assessment, and interventions in the client's medical record. D) Do not file an event report unless the client is seriously injured in the fall.
The nurse is preparing to take an apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope at which cardiac site?
1. Aortic area 2. Mitral area 3. Tricuspid area 4. Pulmonic area
When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.
a. Reflects electrical impulse beginning at the SA node. b. Indicated electrical impulse beginning at the AV node. c. Reflects atrial muscle depolarization. d. Identifies ventricular muscle depolarization. e. Has duration of normally 0.11 seconds or less.