During a head-to-toe assessment, the nurse assesses the patient's perineal area. Which area should the nurse assess next?
a. Chest
b. Arms
c. Abdomen
d. Legs and feet
D
When performing a head-to-toe assessment, the nurse begins with a neurological assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
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When admitting a trauma victim from a motor vehicle accident, the nurse should assess for liver trauma, especially if the patient presents with
A) damage of the spleen. B) fracture(s) of the right lower ribs. C) fracture(s) of the left lower ribs. D) small bowel trauma.
The nurse is exposed to the client's blood and body fluids via an accidental used needlestick. Which would be appropriate nursing documentation of the event?
1. Document "Nurse stuck by used needle" in the client's medical record. 2. Document "Accidental exposure of nurse to blood and body fluid" in the client's medical record. 3. There is no need to document the exposure as long as the nurse takes the proper actions and notifies the charge nurse. 4. Completion of an incident report.
The nurse realizes that the most effective way to prevent healthcare-associated infections is:
a. proper disposal of used tissues. c. isolation of infected clients. b. good handwashing technique. d. administration of appropriate vaccines.
The FHR is controlled by the
A. Sympathetic nervous system B. Sinoatrial node C. Atrioventricular node D. Parasympathetic nervous system