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RNleadership
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Which of the following findings should the nurse identify require follow-up by the provider? Select the 6 findings that require immediate follow-up. Exhibit 1: Day 1, 1715: Client is 6 hr postopera... tive following abdominal surgery. Client is resting and easily awakened. Alert and oriented to person, place, and time. Incision has moderate amount of serous sanguineous draining on dressing. Abdominal dressing is intact. States pain level is a 4 on a 0 to 10 pain scale. Bowel sounds are normoactive. Client tolerating sips of water. Urinary output 320 mL in last 4hr. Day 1, 2030: Nurse enters room client's room. Client is restless and short of breath. Client rates pain as an 8 on a scale of 0 to 10, saying, "My abdomen hurts so bad." Nurse notes dressing site has large amounts of bright red blood. -Blood pressure -Bowel sounds -Pain level -Respiratory rate -Urinary output -Heart rate -Orientation status -Oxygen saturation - Answer When analyzing cues, the nurse should identify that an increase in heart rate, respiratory rate, a pain level of 8 on a scale of 0 to 10, a large amount of bright red blood on the client's abdominal dressing, along with a decrease in blood pressure and oxygenation saturation are manifestations of hemorrhage. Therefore, the nurse should notify the client's provider of these findings immediately. A charge nurse is reviewing the plan of care for a client who has active herpes simplex lesions. Which of the following interventions is appropriate for the plan of care? a. Admit the client to a private room with negative-pressure airflow. b. Wear a gown and gloves when caring for the client. c. Have the client wear a mask during transport. d. Wear a face mask and eye protection when caring for the client. - Answer b. Wear a gown and gloves when caring for the client. The nurse should use contact precautions when caring for clients who have an infection from herpes simplex. Barriers with gloves and gowns are mandatory. A nurse is caring for several clients. Which of the following actions should the nurse take to maintain client confidentiality? a. Tell a client's partner that the client's laboratory tests cannot be disclosed without permission. b. Ask the assistive personnel (AP) to refer to clients by room number in public areas. c. Explain to a nursing student that verbal permission must be obtained before using a client's name in school assignments. d. Share information about [Show More]
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