An apical pulse is usually counted for:
a. 15 seconds.
b. 30 seconds.
c. 45 seconds.
d. 60 seconds.
D
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The nurse is concerned that a client with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data indicates that the client is experiencing an alteration in perfusion?
Select all that apply. A) Skin turgor 20 seconds B) Peripheral pulses present and full C) Capillary refill of nail beds 3 seconds D) Oriented to person, place, and time E) Bowel sounds sluggish in all four quadrants
Which activity should the nurse implement for the toddler hospitalized with a chronic illness to promote autonomy?
a. Playing with a push-pull toy b. Putting together a puzzle c. Playing a simple card game d. Watching cartoons on television
The nurse is preparing to ambulate a patient who sustained burns over 20% of his lower extremities. Which of the following should be done to facilitate the success of the patient's ambulation?
1. have the patient dangle the legs over the side of the bed first 2. use a tilt table before getting the patient out of bed 3. transfer the patient to a chair before ambulating 4. apply compression wraps to the lower extremities before getting out of bed
A person with cystitis may have which of the following signs and symptoms?
a. Shaking and chills b. Dysuria and urinary urgency c. Diarrhea d. Changes in skin color and dry, itchy skin