A nurse documents a paralyzed client's right heel ulcer as a stage 3 pressure ulcer
Which describes a stage 3 pressure ulcer?
A) Painless subcutaneous ulcer with foul-smelling discharge
B) Painful and swollen shallow ulcer or blister
C) Pressure-related changes of intact skin
D) Small wound with extensive underlying damage
A
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The nurse is preparing a 5-year-old for a radiograph. Which of the following would be the best communication to prepare the child for the procedure?
A) "We are going to take some x-rays of your body." B) "We need to look inside at some of your organs." C) "X-rays are not painful; you won't feel a thing." D) "We are going to use a big camera to take pictures inside your body."
A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse?
A) "Nitroglycerine causes headaches, but removing the patch decreases the incidence." B) "You do not need the effects of nitroglycerine while you sleep." C) "Removing the patch at night prevents drug tolerance while keeping the benefits." D) "Contact dermatitis and skin irritations are common when the patch remains on all day."
Which statement from the parents of an 11-year-old child supports the need for parent education on the topic of physical discipline?
A) "Authority figures, such as parents, should be trusted and respected, not feared." B) "Hitting increases the probability that you are more likely to use aggression to handle conflicts." C) "Spanking is an effective method to let a child know that inappropriate behavior is not tolerated and that it has consequences." D) "Corporal punishment gives the message that violence is acceptable."
A nurse is caring for a client with congestive heart failure. The client is ordered to receive nesiritide (Natrecor). The nurse evaluates the effectiveness of this medication by noting which desired effect?
a. Vasoconstriction b. Oliguria c. Decreased diuresis d. Decreased shortness of breath