The nurse assesses an area of drainage on the dressing of a postanesthesia care client's surgical wound. Which of the following should the nurse do?
1. Call the surgeon right away.
2. Cover the dressing with a new dressing.
3. Circle the area and mark it with the date and time.
4. Pass it off to the next shift.
3
If any drainage is showing on the dressing, the nurse is to circle the area and mark it with the date and time. The surgeon does not need to be phoned unless excessive bleeding or hematoma formation has occurred. The dressing does not need to be covered with a new dressing. The nurse should not pass this finding off to the next shift.
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While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to
a. promote rest to decrease myocardial oxygen demand. b. teach the patient about the need for anticoagulant therapy. c. teach the patient to use sublingual nitroglycerin for chest pain. d. raise the head of the bed 60 degrees to decrease venous return.
Which are needed by the candidate to arrange for and take the NCLEX-PN examination? (Select all that apply.)
a. An authorization-to-test letter b. An appointment at a testing center c. A picture identification and one other acceptable form of identification d. A copy of one's fingerprint card
You are performing a review of systems on an 8-month-old infant. The infant is awake and calm. What would be the best way to begin this exam?
a. Perform the most distressing part of the exam first b. Examine the heart, lungs, and bowel sounds c. Perform the rectal temperature first d. Look at the patient's chart to see what was done first on the previous shift.
In an adult, a brain tumor that blocks the flow of cerebrospinal fluid through the ventricular system causes dilation of the ventricular system, but the head does not enlarge as the ventricles enlarge
Indicate whether the statement is true or false