The client is 1-day postoperative; the surgical incision is hard to the touch, has mild, localized swelling, and has not leaked. Which should the nurse include on the client's documentation about the incision? (Select all that apply.)
1. Indurated
2. 1+ edema
3. Healing well
4. Clean and dry
5. Sterile dressing
6. Without drainage
1, 2, 6
1, 2, and 6. Suitable documentation for the client's surgical incision includes "indu-rated," "1+ edema," and "without drainage" because these statements accurately, clearly, and objectively reflect the incision's appearance.
3. "Healing well" is a subjective statement and open to interpretation. In its place, the nurse documents that the wound edges are well approximated without gaps, redness, or tension, clinical indicators of potential infection.
4 and 5. "Clean and dry" and "sterile dressing" are comments about the dressing.
You might also like to view...
A client with chronic renal failure has developed uremic pericarditis. In assessing the cardiovascular system of this client, what sounds would the nurse expect to hear?
A. A harsh, blowing murmur at the left sternal border B. An irregular heartbeat, accompanied by a precordial lift C. A pericardial friction rub, present in systole and diastole D. Soft, distant heart sounds accompanied by an S3
Which term describes how much fluid is to be infused intravenously?
a. Rate b. Infusion c. Volume d. Duration
Which of the following patients is at risk for developing urinary tract cancer?
a. The 45-year-old woman who is 100 lbs overweight b. The 78-year-old man who smokes three packs of cigarettes a day c. The 84-year-old man who worked in the asbestos mines d. All of the above
The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern:
a) The BP is 90/40 mm/Hg c) Oral fluid intake is 100 mL for the last 8 hours d) There is prolonged skin tenting over the sternum