When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first?
A) Perform hand hygiene.
B) Insert a swab into the wound at 90 degrees.
C) Measure the width of the wound with a disposable ruler.
D) Assess the condition of the visible wound bed.
Ans: A
Hand hygiene should precede any wound assessment or wound treatment.
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The nurse plans care for four patients and assigns patient feeding to nursing assistive personnel (NAP). Which patient should the nurse watch during mealtime?
a. The patient who refuses most of the meals served b. The patient who is learning to use adaptive utensils c. The patient who swallows four times for each piece of food d. The patient who is taking ice chips on the first postoperative day
The client with recurrent constipation has been prescribed psyllium (Metamucil). Teaching provided by the nurse should include which of the following instructions?
1. Mix the psyllium powder with any cold beverage. 2. Mix the psyllium powder with 4 oz of a hot beverage. 3. Mix the psyllium powder with gelatin, applesauce, or pudding. 4. Mix the psyllium powder with 8 oz of water or juice followed by drinking an additional 8 oz of liquid.
Community-oriented nursing needs vary by community. However, there are prevailing needs in most rural areas, especially the following:
1. Occupational health 2. Acute hospital care 3. Emergency care services 4. Psychiatric in-patient care
The urologist discusses possible treatment options with A.B. Identify three treatment options
for prostate cancer. Watchful waiting: This involves simply monitoring A.B.'s condition and intervening if symptoms become troublesome. Brachytherapy: Radioactive seeds are implanted in the prostate (these people have irritative voiding symptoms [frequency] for months after the procedure), or external beam radiation can be used. Hormone therapy: A PSA is drawn and medications are given based on PSA levels. In some patients, medications are given to shrink the tumor before surgery. Chemotherapy: Systemic cytotoxic chemotherapy might be done for patients whose cancer has metastasized.