A client suffering from severe hypothermia also is noted to have a cool, numb foot. The foot is blue in color and does not blanch. What degree of frostbite would this be?
A. First-degree frostbite
B. Second-degree frostbite
C. Third-degree frostbite
D. Fourth-degree frostbite
C
Third-degree frostbite appears as small blisters that contain dark fluid. The affected body part is cool, numb, blue or red, and does not blanch. First-degree frostbite involves hyperemia and ede-ma formation. With second-degree frostbite, large fluid-filled blisters develop, with some skin necrosis. In fourth-degree frostbite, there are no blisters or edema and the body part is numb, cold, and bloodless.
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A postpartum client with a difficult vaginal delivery 36 hours ago tells the nurse that she has not felt the need to void much since delivery. The nurse would respond with which of the following statements?
1. "The inside of your bladder is most likely swollen, which makes you feel like you don't have to urinate.". 2. "You must be overdoing it with your activity level so soon after delivery.". 3. "I will need to catheterize you.". 4. "Your uterus must not be enlarged any longer.".
After receiving shift report, which of the following clients should the nurse assess first?
A. Kussmaul respirations B. Blood glucose of 144 C. Pain level 6 out of 10 D. Temperature is 101.8°F
Which physical assessment finding does the nurse would expect in a client with left-sided heart failure?
1. Enlarged liver 2. Lung congestion 3. Jugular vein distension 4. Peripheral edema
How should a patient be positioned for a cleansing or oil-retention enema?
A. In the supine position B. In the prone position C. Lying on the right side D. In the left-lying Sims' position