During dressing changes, the nurse assesses a client who has had breast reconstruction. Which finding would cause the nurse to take immediate action?
a. Slightly reddened incisional area
b. Blood pressure of 128/75 mm Hg
c. Temperature of 99 ° F (37.2 ° C)
d. Dusky color of the flap
ANS: D
A dusky color of the breast flap could indicate poor tissue perfusion and a decreased capillary refill. The nurse should notify the surgeon to preserve the tissue. It is normal to have a slightly reddened incision as the skin heals. The blood pressure is within normal limits and the temperature is slightly elevated but should be monitored.
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A parent brings her child to the pediatric clinic and reports that the child has a rash on one side of his body that reminds her of chickenpox, but is more painful. Which medication does the nurse anticipate teaching the parent about?
A. Acyclovir (Zovirax) B. Azathioprine (Imuran) C. Diphenhydramine (Benadryl) D. Intravenous immune globulin (IVIG)
Advance directives differ from informed consent in that advance directives:
a. are guidelines to be used only if a client cannot make medical decisions for him- or herself b. are only used for specific procedures and expire after the procedure is performed c. can be obtained from a client who is sedated, while informed consent cannot d. only apply to medical treatments and interventions and cannot be used to direct future nursing care
A/an ____________________ hospital cares for children from birth to age 18.
Fill in the blank(s) with the appropriate word(s).
A nurse is preparing to administer enfuvirtide to a client. Which of the following actions should the nurse plan to perform?
A. Administer the drug subcutaneously. B. Roll the vial gently to reconstitute the solution. C. Inject the solution at room temperature. D. All of the above.