The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
a. Ask the patient about a history of frostbite.
b. Suspect that the patient has venous insufficiency.
c. Consider this a delayed capillary refill time, and investigate further.
d. Consider this a normal capillary refill time that requires no further assessment.
ANS: C
Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.
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After providing care to a non-English speaking patient, the nurse is overheard asking the manager what the nursing staff can do to make the U.S. health care system less intimidating for the patient. The nurse is engaging in the practice of:
A) Cultural diversity B) Cultural competence C) Cultural humility D) Cultural influences
Which of the following techniques yield a simple random sample?
A. choosing volunteers from an introductory nursing class to participate B. listing individuals by ethnic group and choosing a proportion from within each group at random C. numbering all elements of a sampling frame and using a random number table to pick individuals D. randomly selecting schools, and then sampling everyone within each school
The client complains of tingling and numbness on the skin under the cold compress. Which should the nurse implement?
1. Reassure client that some numbness is expected. 2. Assess the client before continuing the treatment. 3. Discontinue treatment because of tissue damage. 4. Provide a warm blanket for the client's treatment.
Describe the assessment you would need to perform to differentiate what might be occurring
with S.K. What will be an ideal response?