The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated?
1. Encourage the patient to ingest more fluids.
2. Assess for pain and warmth.
3. Cover the wound with a sterile dry dressing.
4. Dress the wound as prescribed.
Answer: 2
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A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate?
a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.
The nurse is admitting a client to a rehabilitation facility after surgery for a hip replacement. The nurse observes the client as appearing depressed
The client denies depression, but states that she is concerned about returning to her regular activities, including walking for exercise, because she is so tired. The nurse understands that :(Select all that apply) Standard Text: Select all that apply. 1. This client has unrealistic goals 2. Stress may be affecting this client's mobility 3. Walking will tire the client 4. The client is at increased risk of disease due to immobility 5. This client is at risk for affective disorder
The apical pulse is measured
A. at the wrist. B. in the groin area. C. over the heart. D. behind the knee.
A patient comes into the clinic with complaints of extreme thirst, extreme urination, and ongoing hunger. Which blood glucose level should the nurse use to determine if the patient has diabetes?
a. 110 mg/dL b. 126 mg/dL c. 185 mg/dL d. 210 mg/dL