A patient recovering from a biopsy of the right femur had pain medication 1 hour ago. Which symptom should the nurse report and closely monitor in this patient? (Select all that apply.)
a. Temperature 98.4°F
b. Hematoma formation
c. Capillary refill of 3 seconds
d. Pain reported as 7 on a 0-to-10 scale
e. Range of motion of the ankle and knee present
ANS: B, D
The nurse inspects the biopsy site for bleeding, swelling, and hematoma formation. Increased pain that is unresponsive to analgesic medication may indicate bleeding in the soft tissue. A. This is a normal body temperature. C. This is a normal capillary refill. E. Full range of motion is an expected finding.
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In caring for victims of violence it is important for nurses to be aware of their personal feelings and attitudes about the situation because:
1. Intense negative feelings interfere with assessment and judgment. 2. It allows the nurse to express sympathy for the client. 3. Intense protective feelings result in appropriate interventions for the victim's care. 4. Self-awareness protects the nurse's own mental health.
The nurse is caring for a client who is having a ruptured appendix removed before peritonitis develops. This is BEST described as which type of prevention?
a. physical prevention c. secondary prevention b. primary prevention d. tertiary prevention
A nurse teaches the patient who is inquiring about a diaphragm:
A) One size fits all females. B) The diaphragm may be cleaned with soap and water after use. C) A diaphragm's effectiveness does not require spermicidal jelly. D) The diaphragm may be removed an hour following intercourse.
Transvaginal ultrasonography is often performed during the first trimester. While preparing your 6-week-gestation patient for this procedure, she expresses concerns over the necessity for this test
The nurse should explain that this diagnostic test may be necessary to determine which of the following? Select all that apply. a. Multifetal gestation b. Bicornate uterus c. Presence and location of pregnancy (intrauterine or elsewhere) d. Amniotic fluid volume e. Presence of ovarian cysts