Care planning information for exam 4. Fund.
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?
Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product?
The dressing allows oxygen exchange between the wound and environment.
When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present?
The nurse is operating under standing orders for clients with suspected MIs.
A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?
discuss possible alternative with the physician
what is the definition of normotensive
having a normal BP
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?
incision
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and the family
A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?
ongoing
Which phase of the nursing process most involves establishing priorities?
outcome identification and planning
The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?
quality assurance
Why are quality-assurance programs important in nursing?
they enable nurses to be accountable for the quality of care
Which are cognitive client outcomes?
The client lists the side effects of digoxin. The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia.
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?
a sterile, flexible applicator moistened with saline
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?
go to the client and assess the chest pain
Which action should the nurse perform during the planning step of the nursing process?
selects nursing measures including client education
Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?
standardized
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?
surveillance
