The nurse is checking for capillary refill on a child in Bryant's traction. How long does it take for the toe to regain color if adequate perfusion is assessed?
a. 3 seconds
b. 4 seconds
c. 5 seconds
d. 6 seconds
ANS: A
Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.
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a. an inability of the heart to pump blood forward. b. hypovolemia, resulting in decreased stroke volume. c. disruption of the conduction system when re-entry phenomenon occurs. d. an inability of the heart to respond to inotropic agents.
A patient's neck dissection surgery resulted in damage to the patient's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?
A) The patient's swallowing ability B) The patient's ability to speak C) The patient's management of secretions D) The patient's airway patency
Prepare an 80 mg dose from a label reading 100 mg/5mL
What will be an ideal response?
The nurse is caring for a client who is intubated following trauma to the chest. Which of the following nursing measures would the nurse perform while the client is intubated?
A) Provide oral care every 4 hours. B) Monitor placement of the endotracheal tube. C) Keep the client lying flat to prevent tube slippage. D) Perform chest compressions every 5 minutes.