A client has a chronic wound that is being treated with a vacuum-assisted wound closure (VAC) device. Which intervention by the nurse takes priority?
a. Provide pain medication as needed.
b. Assess the VAC every 2 hours for bleed-ing.
c. Check the integrity of the dressing seal every 4 hours.
d. Document the wound size with each dressing change.
B
VACs have been associated with serious bleeding complications. All of these interventions are important, but assessing for bleeding takes priority because it enhances client safety.
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Which of the following assessment findings may indicate right-sided heart failure?
A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea
The 75-year-old client states that when she senses the need to urinate, she is unable to inhibit voiding before she reaches the toilet. What advice would help her incontinence?
A) "Don't drink any liquids after 6 pm. This will decrease your urine volume.". B) "Make a urination schedule as to when you are incontinent during the day.". C) "Remind yourself to urinate every two hours during the day.". D) "You need to tell your doctor because this is very unusual.".
The nurse is completing an initial assessment on a client diagnosed with depression. Which of the following is an example of cognitive assessment data?
A) Perception of current problem B) Employment status C) Current living situation D) Family relationships
The home health nurse points out the benefits of regular exercise, which include __________________________________. (Select all that apply.)
a. maintenance of joint mobility. b. enhancement of muscle tone. c. promotion of sense of general well-being. d. enhancement of weight loss. e. promotion of regular elimination.