A patient was admitted 2 hours ago to the postsurgical unit from PACU following a Hartmann's resection (bowel surgery)
During the nurse's most recent assessment of the patient, significant bleeding was noted on the patient's abdominal dressing, which was previously dry and intact. What action should the nurse perform first?
A) Apply a transparent dressing over the existing bandage and position the patient side-lying.
B) Remove the patient's dressing and insert gauze packing if dehiscence is apparent.
C) Check the results of the patient's preoperative blood group and screen,
D) Apply a sterile gauze and hold it in place while applying moderate pressure.
D
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A patient taking warfarin (Coumadin) has just begun chemotherapy. The patient comes to the clinic for a follow-up appointment and complains of blood in her urine. The nurse's most imme-diate action should be to
a. advise the patient that this is normal with this type of drugs. b. check the platelet count for thrombocytopenia. c. advise the patient that she will need to skip the next round of chemotherapy. d. administer epoetin (Epogen) subcutaneously.
A client in your care in a nursing home asks for nutritional pudding supplements all day. You notice that staff often respond to the request and then the client does not eat the food served at mealtime. You decide to:
1. Post a chart that staff must sign when they give the client pudding, and limit the servings to twice a day at least two hours before or after meals. 2. Ignore the problem since the client probably gets more nutrients eating the supplements than eating the meals. 3. Inform the client that too many servings of pudding are not good and meals are a better nutritional option. 4. Ask the kitchen to provide the client with small portions of meals since they are discarded anyway.
The nurse is administering a blood transfusion to a client. Which should the nurse implement first when a client is complaining of chills and back pain within the first 15 minutes of this transfusion?
A. Infuse normal saline. B. Give the client a blanket. C. Stop the infusion. D. Notify the charge nurse.
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy."
Which intervention would be most helpful for the parents? A) Explaining to them about the diagnosis and surgery B) Having a wound, ostomy, and continence nurse meet with them C) Reinforcing that the ostomy will be temporary D) Teaching them about the medications used to slow stool output