The nurse has been assigned to care for a client who had a t…
The nurse has been assigned to care for a client who had a total knee replacement five hours ago. The nurse assesses the surgical dressing and finds sanguineous drainage on the outside of the dressing about 3 cm in diameter. What is the most appropriate action by the nurse?
Read DetailsThe client scheduled for an elective hysterectomy tells the…
The client scheduled for an elective hysterectomy tells the nurse that they do not know whether they can go through with the surgery because they know they will die in surgery like their mother. What is the most appropriate response by the nurse?
Read DetailsThe nurse delegates routine vital signs on five clients to a…
The nurse delegates routine vital signs on five clients to a UAP/CNA. The nurse is communicating this delegation to the UAP/CNA. Which is the best statement to ensure that the nurse obtains priority findings from the UAP/CNA?
Read DetailsA nurse is caring for a post-operative mastectomy client. Th…
A nurse is caring for a post-operative mastectomy client. The client has been on the nursing unit for four hours since transferring from the Post Anesthesia Care Unit (PACU). The following is the most recent client assessment: stable vital signs pain is 3 on the 0-10 scale has not voided yet taking fluids without nausea. What is the best action by the nurse at this time?
Read DetailsThe nurse is caring for a client on a medical surgical unit…
The nurse is caring for a client on a medical surgical unit who returned from surgery 45 minutes ago. The nurse reviews the flow sheet below. What is the most appropriate action by the nurse? Flow Sheet Time Blood Pressure Pulse Respirations Pulse Oximetry Temperature Pain Rating Level of Consciousness IV & rate 1300 120/70 87 14 94% 98.4 oral 3 Drowsy D5 0.45NS at 125 mL 1315 116/76 86 16 96% 98.6 oral 3 Drowsy, arouses easily D5 0.45NS at 125 mL 1330 118/66 82 14 97% 98.8 oral 3 Drowsy, arouses easily D5 0.45NS at 125 mL
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