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The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change? a. After the dressing changeb. At least 15 minutes before the dressing changec. At least 30 minutes before the dressing changed. At least 1 hour before the dressing change

Your client is on a full liquid diet and has taken in 240 ml of chicken broth and 60 ml of sherbet. He has an IV running at 100ml/hr. He has a Foley catheter that has 500 ml concentrated urine. He has complained of nausea and vomiting twice with a total output of 200 ml of emesis. Calculate the output for the 8-hour shift.   a. 700 mlb. 1100 mlc. 500 mld. 800 ml  

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates? a. Cellulitisb. Dehiscencec. Eviscerationd. Extravasation  

You are admitting a patient and are performing a skin assessment. Upon assessment, you find a stage III pressure ulcer on the patient’s ischial tuberosity. Identify all priority integumentary nursing assessments:  a. Pain assessmentb. Measurements, including depth, width, and heightc. Characteristics of exudate/ drainaged. Home nutrition regimene. Tissue quality in wound bed

The nurse assessing a patient’s wound notes thick, yellow drainage. How will the nurse most accurately document this finding? a. Serous drainageb. Purulent drainagec. Sanguineous drainaged. Serosanguineous drainage

The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient learning about? a. Sterilizationb. Standard Precautionsc. Hand hygiened. Medical asepsis  

Infiltration of the intravenous infusion is suspected when the: a. drip rate speeds up suddenlyb. erythema and warmth are present in the surrounding areac. tissue near insertion is cool and edematousd. a rash and itching are noted at the site  

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed? a. Destruction of tissueb. Bleedingc. Mechanical debridementd. Prevention of infection

The nurse notes that the client’s surgical dressing is saturated and wet with sanguineous drainage one hour post-operatively. The nurse does which of the following? Select All That Apply. a. Notify the MD.b. Reinforce the dressing.c. Connect the drainage system to suction. d. Assess the client’s vital signs.e. Note the color and amount of drainage.

Select all of the disadvantages for oxygen masks: