A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?
A) Immediately report to the physician that the patient has a pressure ulcer.
B) Recognize that this is ischemia, followed by reactive hyperemia.
C) Document the presence of a pressure ulcer and develop a care plan.
D) Implement nursing interventions for Altered Skin Integrity.
B
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The nurse uses the "risk for" nursing diagnoses as identified from the:
a. care plan. b. interventions. c. assessment. d. evaluation.
A client tells the nurse that she is too busy with work and providing for her family to stop and think about spirituality. Which of the following might be helpful for this client?
a. Guided imagery b. Progressive relaxation c. Exercise d. Mindfulness
The nurse is preparing to administer medications to a patient taking sucralfate (Carafate) and ciprofloxacin (Cipro). The drugs are ordered for 0900 . In what manner should the nurse proceed to administer the drugs?
a. The nurse should administer the drugs with a full glass of water. b. The nurse should ask the prescriber to change the times to prevent concurrent administration. c. The nurse should administer the two drugs at same time with food. d. The nurse should administer the ciprofloxacin 15 minutes before the sucralfate.
The nurse is teaching a newly diagnosed diabetic patient about metformin. What information does the nurse include? (Select all that apply.)
a. Alcohol intake should be limited and tak-en with food. b. Overweight patients sometimes poorly tolerate metformin. c. Oral hypoglycemic agents can increase the risk of hyperglycemia. d. Metformin has been the cause of anorexia in older patients. e. Oral hypoglycemic agents affect vitamin D absorption.