The nurse inspects a patient's surgical incision and notes dehiscence several inches long. Which is the most important intervention for the nurse to implement?
a. Call for assistance.
b. Place a sterile moist dressing on the wound.
c. Apply direct pressure over the wound dressing.
d. Apply a pressure dressing over the open area.
B
The most important interventions for the nurse to take are to have the patient lie still, place moist sterile dressings over the area and cover it with dry pads, and notify the healthcare provider. The nurse should not put any pressure on the area that has dehisced. A pressure dressing is contrain-dicated for this type of opening. A pressure dressing would be used over a bleeding wound or puncture area after a procedure.
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The waiting room of the mental health clinic is full of children with various mental health issues. The nurse watches the children and notes that which child is displaying symptoms of autism?
1. Four-year-old girl who doesn't make eye contact with mother and resists the mother's touch 2. Three-year-old boy who joins one group of children then moves to another group of children without joining their activities 3. 18-month-old child who walks around the area using the furniture to provide balance 4. Six-year-old boy who chatters constantly to anyone who will listen
Which information would the nurse include in the assessment category when using SOAP to documents in the medical record?
1. The client's blood pressure was 177/93. 2. The recent loss of employment and insurance has prevented the client from being able to afford prescription medications. 3. The client reports having lost her job and insurance 3 months ago. 4. Referrals have been made to social services to determine financial assistance programs available.
patient recovering from a burn to the left side of his face tells the nurse that he has no idea how he is going to return home and resume his regular life since he is so "ugly and disfigured." What nursing response is indicated?
1. "It is good that your work does not include having to meet the public every day." 2. "I don't think your scars are so bad." 3. "I think you should see a plastic surgeon before you try to go back to work." 4. "Would you like a referral to the Phoenix Society?"
The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client?
a. "You may lift items up to 10 pounds." b. "Wear your brace when you are out of bed." c. "You must remain on bedrest for 48 hours after surgery." d. "You will need to take steroids to prevent rejection of the bone graft."