After invasive procedures to assess the respiratory system, which of the following signs should the nurse assess?
A) Watery sputum C) Respiratory distress
B) Loss of consciousness D) Masses in pleural space
C
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The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct?
Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
The nursing faculty member explains to a class of nursing students the correct way to assist with perineal care (peri-care) after childbirth. Which action by a student nurse would warrant intervention by the faculty member?
A. Has woman squirt warm water toward the front of the perineum B. Instructs the woman to wash her hands prior to peri-care C. Removes the peri-pad from back to front and appropriately disposes of it D. Washes the hands before assisting woman with her peri-care
Juanita was brought to the hospital by her daughter-in-law, Alejandra, who lives within a few miles of her in a remote area of the state
Juanita will be kept in a semi-private room for overnight observation and Alejandra plans to stay at Juanita's bedside for a couple of hours so she can find out what is going on before she leaves to check into a motel for the night. Juanita's nurse checks in on her patient and asks Alejandra what her relationship is to Juanita. Upon learning this information, what is the best response by the nurse? 1. "I'm afraid that, due to HIPPA regulations, we have a hospital policy that we can only share information about the patient with Juanita's extended family such as her husband or children." 2. "I'll need you to step out in the hallway so that I can talk to you about Juanita's medical status; it's an issue of confidentiality and we need to protect personal health information." 3. "I'll need to check with Juanita to make sure it's okay if I discuss her medical status with you." 4. "I'm sorry, but due to HIPPA regulations, we can't have visitors stay at the bedside when the patient is not in a private room."
At the moment of insertion of a central venous line, the nurse instructs the client to:
A. Cough B. Swallow C. Hold the breath and bear down D. Breathe through the mouth quickly