After surgery a patient's surgical dressing covering the Penrose drain is dry and intact
Two hours later, the patient reports pain of 5 on a scale of 0 to 10 at the incisional site and the dressing has a 1 ? 1 inch area of serosanguineous drainage on the dressing. What actions should the nurse take? (Select all that apply.)
a. Apply pressure to the incisional site.
b. Culture the drainage on the dressing.
c. Notify the RN immediately.
d. Monitor the drainage at the incisional site.
e. Review the analgesic administration record.
ANS: D, E
Moderate serosanguineous drainage is expected from a Penrose drain, so monitoring the dressing is all that is needed at this time, as this is a small amount of drainage. The pain level requires intervention, and verifying the last time pain medication was administered is the first step. A. Pressure does not need to be applied to the incisional site. B. The drainage does not need to be cultured. C. The RN does not need to be notified.
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The home care nurse is caring for a patient newly prescribed a nonselective beta-blocking agent. What would the nurse include in the teaching plan related to this drug? (Select all that apply.)
A) Take with meals. B) Change position slowly. C) Avoid driving or operating hazardous machinery. D) Warn of possible increase in libido. E) Increase activity levels as much as possible.
The nurse provided education about the tetanus toxoid and administered it to the client via injection after stepping on a nail while walking on the beach. Which statement by the client indicates successful teaching?
1. "The tetanus toxoid is caused by viruses." 2. "The tetanus toxoid is caused by parasites." 3. "The tetanus toxoid is an optional treatment so I really don't have to have this." 4. "The tetanus toxoid are toxins that have been altered so that they are no longer toxic."
A nurse practitioner wishes to send e-mail to all clients on a distribution list without displaying the e-mail addresses of those on the list to the recipients. Which of the following will appropriately accomplish this task?
1. Include the nurse practitioner's e-mail address as primary recipient and the client addresses as carbon copies (CC). 2. The nurse practitioner must send a separate message to each individual client as primary recipient. 3. Include the nurse practitioner's e-mail address as primary recipient and the client addresses as blind copies (BCC). 4. Include the recipient e-mail addresses as primary recipients and the nurse practitioner's address as a blind copy (BCC).