The nurse assesses an open area over a patient's greater trochanted that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional findings would indicate to the nurse that this is a Stage IV pressure ulcer:
a) The crater extends into the subcutaneous tissue
b) The joint capsule of the hip is visable
Answer: b) The joint capsule of the hip is visable
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The patient's arterial pressure waveform has a rapid upstroke, a clear dicrotic notch, and a definite end-diastole. What is the best nursing action?
A) Re-level the system. B) Manually flush the system. C) Obtain manual cuff pressure. D) Continue with the plan of care.
The nurse assesses the patient taking anabolic steroids for what serious adverse effects?
A) Elevated blood urea nitrogen (BUN) B) Elevated blood glucose level C) Bradycardia D) Jaundice
Spreading cells from a cytobrush on a slide after a specimen is collected should be done by:
A) Sliding the cytobrush back and forth. B) Using a rolling motion. C) Brushing the specimen on the slide vigorously. D) Lightly dabbing onto the slide.
A neonate is born to a diabetic mother. The baby is very large, weighing 10 lb. The nurse plans care of the neonate accordingly. Nursing care will include:
a. Holding feedings to help reduce blood glucose b. Monitoring blood glucose levels carefully c. Checking vital signs each shift d. None of the above