Which of the following instructions should a nurse provide as the single most important measure to prevent the spread of infection?
A) Minimal social contact C) Thorough hand washing
B) Regular immunizations D) Sufficient food intake
C
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The nurse notes mucous shreds in the urine of a client with an ileal diversion. The nurse's priority action is to:
1. Document the finding. 2. Notify the supervisor. 3. Ensure that the client is ordered an antibiotic. 4. Encourage the client to increase fluids.
Which documentation entry reflects objective data?
a. An area of erythema is noted on the upper right extremity, measuring approximately 1 ? 4 inches. b. The patient complains of pain in the right left quadrant (RLQ) of the abdomen and rates it 5 on a pain scale of 1 to 10. c. The family states that the patient does not sleep at night and wanders around the house. d. The medical history reveals a history of drug abuse.
A surface wound involving loss of the epidermis and possible partial dermal loss is called a(n)
a. laceration c. evisceration b. abrasion d. ecchymosis
The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion?
1. Enrolled in online classes 2. Raising two children ages 4 and 8 3. Experiences chronic pain from sciatica 4. Attends religious services every Sunday and Wednesday 5. Works one job steady night turn and another part-time late afternoon