A victim of a motorcycle accident has an open fracture of the left femur with an associated wound of 8 cm. The nurse's assessment records this injury as grade
a. I.
b. II.
c. III.
d. IV.
C
A grade III wound is 6 to 8 cm in length with accompanying extensive tissue damage and high degree of contamination. A grade I is smaller than 1 cm with minimal contamination. A grade II wound is larger than 1 cm with moderate contamination. The classification system stops at grade III.
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The nurse is working in a long-term care facility. As clients are assessed, the nurse notes that one client is confused and incontinent, which is new behavior for the client. The nurse should further assess the client, suspecting:
1. the client has had a stroke. 2. the client's oxygen level is decreased. 3. the client has cystitis. 4. the client has kidney stones.
While bathing a patient, a nurse recognizes that the personal space-distance zone that he or she is in when physically touching the patient is
1. Public. 2. Intimate. 3. Casual-personal. 4. Social-consultative.
An adult patient sustains third- and fourth-degree burns to more than 70% of her body related to a house fire
The patient begins a pattern of behavior similar to that of a young child, in which she repeatedly whines and throws "temper tantrums" in an attempt to keep her nurse at the bedside. The patient's coping mechanism is consistent with a. regression. b. identity disturbance. c. denial. d. trust.
When preparing to start an intravenous infusion on an adult, the nurse should:
A) prepare the skin with 70% alcohol and povidone-iodine. B) apply sterile gloves before inserting the intravenous device. C) place a cold cloth over the intended site for greater access. D) place a tourniquet 2 below the selected site.