While making rounds, the charge nurse observes a staff nurse cleaning a surgical wound and notes that the staff nurse has cleaned the wound from the top to the bottom of the wound. Which action should the charge nurse take in this situation?
A. Request the staff nurse clean the wound again using a circular motion and cleaning from outside the wound to the wound itself.
B. Make arrangements for the staff nurse to visit the education department for retraining in wound cleaning.
C. Continue with rounds with the knowledge that the staff nurse used the proper cleaning technique.
D. Inform the staff nurse that the charge nurse will be observing the client for signs of infection.
Answer: C
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A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond?
a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."
The rationale for administration of a fibrinolytic agent is
a. dilation of the blocked coronary artery. b. anticoagulation to prevent formation of new emboli. c. dissolution of atherosclerotic plaque at the site of blockage. d. restoration of blood flow to the obstructed coronary artery via lysis of the thrombus.
The nurse will use which of the following physical assessment techniques when assessing a patient for cardiac output?
1. inspection, percussion, auscultation 2. inspection, palpation, percussion 3. inspection, palpation, diaphragmatic excursion 4. inspection, auscultation, palpation
A client has just had a cup of coffee, and the nurse needs to measure the body temperature. The nurse should:
A. Take a rectal temperature B. Take an axillary temperature C. Use a tympanic membrane sensor D. Postpone the measurement for 5 minutes