The nurse would know care for a stage II pressure ulcer is achieving the desired goal when:
a. The ulcer is completely healed with minimal scarring
b. The patient reports no pain at the site
c. A minimal amount of drainage is noted
d. The wound bed contains 100% granulated tissue
ANS: D
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Following diagnosis of Ewing's sarcoma, the physician orders chemotherapy for the 12-year-old child. After discussion with the physician, the parents refuse a central line so the chemotherapy will be administered by peripheral line
The nurse will prevent extravasation by: Standard Text: Select all that apply. 1. Ensuring that the intravenous line is a free flowing line. 2. Administering the medication by infusion pump. 3. Checking for blood return before and during chemotherapy administration. 4. Diluting the medication with normal saline. 5. Administering the vesicant drug last.
The school nurse is discussing challenges of the adolescent years with a group of high school students in health class. What challenges toward adolescent development will the nurse include?
a. Developing intimacy b. Maintaining dependence on parents c. Searching for identity d. Adjusting to body changes e. Establishing future goals
Through a routine complete blood count, a patient is found to have a platelet count of 90,000/mcL. The nurse realizes that which of the following should be done for this patient?
1. limit the ingestion of green leafy vegetables 2. implement bleeding precautions 3. restrict fluids 4. monitor urine output
The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which of the following responses by the nurse would explain why this practice should be changed?
1. "If you continue to ignore the urge to defecate, the urge is ultimately lost.". 2. "It is better to suppress the urge than to suffer embarrassment at work.". 3. "This is a common practice, and it will strengthen the reflex later.". 4. "You will get the urge later; don't worry.".