The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800 . At 1400, the nurse notices that the dressing is saturated. What is the nurse's next action?
a. Wait and change the dressing at 1800 as ordered.
b. Revise the plan of care and change the dressing now.
c. Reassess the dressing and the wound in 1 hour.
d. Discontinue the plan of care.
B
Based on evaluative data, the nurse revises, discontinues, or continues a patient's plan of care. Because the dressing is saturated, the nurse needs to revise the plan of care and change the dressing now. Waiting until 1800 or for another hour is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.
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The nurse is performing an assessment on a patient who has presented to the emergency room with dilated cardiomyopathy (DCM). Which of the following changes in the heart characterizes DCM?
A) Dilated ventricles with hypertrophy of the ventricles B) Dilated ventricles without hypertrophy of the ventricles C) Hypertrophy of the ventricles with no dilation of the ventricles D) Dilation of the atria and hypertrophy of the ventricles
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A patient has been diagnosed with acute myeloid leukemia (AML). The nurse anticipates that the plan of care for this patient will most likely include:
A) Aggressive chemotherapy treatment B) Chronic albumin transfusion C) Treatment with vancomycin D) Interferon injections
Which activity will best affect success in preparing to master the 'school setting' when getting ready to enter into an ADN nursing program?
A) Attending the school's orientation for incoming students B) Visiting the school to explore the various campus locations C) Developing contacts with current school of nursing students D) Becoming familiar with the information on the school's official website