The nurse removes the client's hydrocolloid dressing and observes minimal clear and watery drainage. Which should the nurse implement?
1. Evaluate for leukocytosis.
2. Change to foam dressing.
3. Collaborate with provider.
4. Document serous drainage.
4
4. The nurse documents that the wound is draining serous drainage after the dressing change to record the wound drainage accurately. Serous drainage is a benign finding.
1. Leukocytosis indicates infection, inflammation, or malignancy. If the client has leukocytosis, the nurse determines that the wound is probably not the cause because serous drainage is a benign finding and inconsistent with clinical indicators of infec-tion.
2 and 3. The nurse uses a dressing indicated for wounds with minimal exudate and does not need to collaborate with the provider because serous drainage from the wound is consistent with a successful wound care protocol.
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A client is recovering from a bronchoscopy. Which assessment finding should be reported to the health care provider? (Select all that apply.)
1. Wheezing 2. Chest pain 3. Sore throat 4. Bloody sputum 5. Shortness of breath
A 20-year-old college student suffers an acute asthma attack. In response to the asthma attack, lymphokines are secreted to:
A) Decrease B cell production B) Increase cell growth C) Decrease macrophages D) Redirect target cells
The nurse is discussing home care of the patient with dementia with the patient's family. The nurse should advise the family to prevent the patient from wandering by:
1. applying a vest restraint to keep the patient in bed or in a chair. 2. putting locks on any doors that it would be dangerous for the patient to open (e.g., outside doors, medicine cabinet). 3. having someone remind the patient at least every 2 hours that he or she must not go outside by himself or herself. 4. setting up a reward system for the times the patient stays where the family has requested.
Which finding should the nurse anticipate in an infant with coarctation of the aorta?A) Higher right ventricular pressure than left ventricular pressure B) Lower blood pressure in the lower extremities than the upper extremities C) Higher blood pressure in the upper extremities than the lower extremities D) Higher blood pressure in the left arm tan the right arm
A) Higher right ventricular pressure than left ventricular pressure B) Lower blood pressure in the lower extremities than the upper extremities C) Higher blood pressure in the upper extremities than the lower extremities D) Higher blood pressure in the left arm tan the right arm