Capillary refill can be assessed by applying pressure over a nail bed or a(n):
a. bony prominence.
b. eyelid.
c. mucous membrane.
d. femoral vein.
A
Capillary refill can be assessed by pressing firmly over a nail bed or bony prominence such as the chin, forehead, or sternum until the skin blanches. Count the seconds it takes for color to return. Less than 2 seconds is a normal finding, and longer than 2 seconds indicates poor perfusion.
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A) "After a certain period of time, you must start warfarin and heparin together." B) "You will need both warfarin and heparin for several days." C) "Warfarin takes 3–5 days to develop anticoagulant effects, and you still need heparin." D) "Warfarin cannot be given without heparin due to the amount of clotting you need."
The nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed
The nurse should instruct the family that the most effective way to prevent urinary incontinence associated with immobility is to: 1. use absorbent underpads. 2. set up a toileting program. 3. restrict fluid intake to 500 mL/24 hours. 4. restrict fluids after dinner and throughout the night.
During active labor, the nurse observes the patient crying during contractions and not using breathing techniques learned during prenatal classes. Which nursing diagnosis would be appropriate for the patient at this time?
A) Risk for fluid volume deficit B) Anxiety related to stress of labor C) Risk for ineffective breathing pattern related to breathing exercises D) Powerlessness related to duration of labor
An older patient's BUN is 28 mg/dL and creatinine is 0.6 mg/dL. How does the nurse interpret these findings?
a. Normal for all age groups b. Normal for older adults c. High for all age groups d. Low for older adults