A nurse is assisting in developing a plan of care for the client with the presence of a blood disorder. Assessment data for this client would MOST likely include which of the following? (Select all that apply.)
a. monitoring for spider angiomas
b. encouraging fluids
c. monitoring the red blood cell count
d. monitoring for purpura
e. encouraging the use of an electric razor
f. preventing ecchymosis from occurring.
A, C, D
Assessment data for a client with the presence of blood disorders include monitoring for pallor, purpura, petechiae, ecchymosis, and spider angiomas.
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Which assessment is considered abnormal when a nurse performs a neurovascular assessment on a patient in skeletal traction?
a. Delayed capillary refill b. Bilateral equal pulses c. Absence of pain and swelling d. Limb is the same color as the unaffected side
A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform?
a. Elevate the patient's left forearm. b. Schedule daily dressing changes to the new IV site. c. Change the administration set. d. Place the patient in Fowler's position.
The nurse is working with an Asian client to provide instruction regarding his medication regimen. The nurse is planning to provide the client with pamphlets to take with him as part of the follow-up to his instructional sessions
What is the most appropriate action on the part of the nurse? a. Make prolonged eye contact with the client. b. Use both hands as a show of respect. c. Show flexibility in making follow-up appointments. d. Speak clearly in a loud voice.