The nurse prepares to irrigate the client's wound. The primary reason for this procedure is to:
1. Decrease scar formation
2. Remove debris from the wound
3. Improve circulation from the wound
4. Decrease irritation from wound drainage
ANS: 2
The gentle washing action of the irrigation cleanses a wound of exudate and debris. The primary purpose of wound irrigation is not to improve circulation, decrease scar formation, or decrease irritation from wound drainage, but to remove debris from the wound.
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Upon checking on a patient, a nurse discovers the patient appeared to experience some shortness of breath while walking back from the restroom. The nurse determines that the patient may be experiencing
1. Episodes of orthopnea. 2. Cheyne-Stokes respirations. 3. Eupnea. 4. Exertional dyspnea.
A client has been taking thyroid hormone replacement for several years. On today's clinic visit, the nurse remarks that the client has lost 20 pounds. The client states, "I was getting fat, so I started taking an extra thyroid pill every day or so."
How should the nurse respond? 1. "Well, it certainly is working for you." 2. "You should follow the dosage instructions for your thyroid medication exactly as written." 3. "I'll ask your physician to increase the number of refills on your prescription." 4. "That could be dangerous to your health." 5. "I may ask the doctor to write a prescription for me."
What action should the nurse take?
A. Notify the HCP of the drainage B. stop the CBI and irrigate the catheter C. Increase the rate of flow of the CBI D. Document that the CBO is infusing correctly
A 33-year-old woman had a laparoscopic cholecystectomy performed this morning and was transferred at 15:00 to the postsurgical unit from PACU. It is now 16:30 . At this point in the patient's recovery, what are the nursing priorities?
A) Health education about the dietary and lifestyle changes necessitated by her gall bladder surgery B) Monitoring and treating the patient's pain, nausea, and vomiting C) Encouraging the patient to ambulate, and teaching the patient about the benefits of early ambulation D) Performing a sterile dressing change and assessing the integrity of the patient's surgical incision