The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention?
a. Edema in the sacrum
b. Skin texture
c. Skin temperature
d. Pallor or mottling of the skin
C
Darkly pigmented skin does not always have visible blanching. Its color differs from that of surrounding skin. Skin temperature changes may be an important early indicator of a stage I pressure ulcer. Edema is not an initial indication of a pressure ulcer. Do not massage any reddened or discolored pressure points. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels. Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin.
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The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply.)
a. Decreased cough reflex b. Decreased lung elasticity c. Increased activity of the cilia d. Abnormal swallowing reflex e. Increased sputum production
An infant of African origin is being cared for by parents who immigrated to the United States 6 months prior. The mother is using an herbal paste to treat the baby's diaper rash. What should the nurse do to ensure cultural competence?
1. Instruct the mother to stop using the paste. 2. Ask the mother to explain the ingredients in the paste. 3. Provide the mother with another cream to use for the diaper rash. 4. Explain to the mother that herbal ingredients are harmful to the baby.
Parenteral pentobarbital should be administered with care because:
a. intramuscular abscesses are common. c. it can cause sedation. b. infiltration can cause tissue necrosis. d. it has a high incidence of phlebitis.
A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately?
a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 7/10 (0 to 10 scale) abdominal pain. c. The patient has absent breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.