A nurse observes a small opening draining purulent material on the skin over the trochanter area of a bedridden client. What is the nurse's next best action?
A. Use a sterile cotton-tipped applicator to probe for a much larger pocket of necrotic tissue.
B. Measure the reddened area on the skin surface and apply a transparent film dressing.
C. Document the observation as the only action.
D. Notify the physician.
A
This "hidden" wound may first be observed as a small opening in the skin through which puru-lent drainage exudes.
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A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.
An IV of Pronestyl 3 g in 500 mL D5W is infusing at 40 mL/hr. What dose is the client receiving? _______________
a. 4 mg/hr b. 4 mg/min c. 240 mg/min d. 60 mg/min
A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis (GCA). What aspect of physical assessment should the nurse prioritize?
A) Assessment for subtle signs of bleeding disorders B) Assessment of the metatarsal joints and phalangeal joints C) Assessment for thoracic pain that is exacerbated by activity D) Assessment for headaches and jaw pain
Using the classical organizational theory model, which would be the most appropriate method for the nurse to voice concern over unfair client workload assignments?
1. Invite the director of nursing to a unit meeting. 2. Circulate a petition to all staff seeking support for change in assignment policy. 3. Organize a unit meeting to discuss the problem on all shifts. 4. Discuss the problem with the team leader, then the manager if the problem persists.