chpt 31 - Chapter 31 1 36 hours after having surgery a patient has a slightly elevated body temp and generalized malaise Which intervention is most

chpt 31 - Chapter 31 1 36 hours after having surgery a...

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Chapter 31 1. 36 hours after having surgery, a patient has a slightly elevated body temp and generalized malaise. Which intervention is most important to include in this pt’s nursing care plan? – DOCUMENT THE FINDINGS AND CONTINUE TO MONITOR THE PT 2. A 16 yr old pt was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the pt says “I am so ugly now”. Based on this statement, what nursing dx would be the most appropriate? -DISTUBRED BODY IMAGE 3. A pt is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? – PERFORMING CAREFUL HAND HYGIENE 4. After an initial assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: - STAGE II 5. Nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as “red”. What would be the priority
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  • Fall '15
  • Rothwell
  • Nursing, Test, Prep, Care, Wound, Wound infection, intention wound repair

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