FUNDAMENTA 102Fundamental of Adaptive quizzes (1).

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A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? " "Moderate amount of drainage." " "No change in drainage since yesterday." " ... "A 10-mm-diameter area of drainage at 1900 hours." " "Drainage is doubled in size since last dressing change." Rationale A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a timeframe. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable. When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? Kidney dysfunction Cardiovascular diseases Eye problems, such as glaucoma Accidents, including their prevention Rationale Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults. A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? Increase fluids.Increase fiber in the diet. Wash hands with soap and water. Wash hands with an alcohol-based hand sanitizer. Rationale Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcoholbased hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile. [Show More]

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