During an assessment of an older adult patient, the nurse observes a red rash on the palms of the hands and the soles of the feet. What should the nurse do next?
a. Notify the charge nurse.
b. Float the patient's heels on a pillow.
c. Apply a prescribed emollient.
d. Reposition the patient on the left side.
A
A red rash on the palms of the hands and the soles of the feet is consistent with the secondary phase of syphilis. The nurse should notify the charge nurse and health care provider to allow for further workup and treatment as indicated. Floating the patient's heels or repositioning addresses prevention of skin breakdown, and emollients help decrease dry skin.
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A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that:
a. After menopause, blood pressure readings in women are usually lower than those taken in men. b. The blood pressure of a Black adult is usually higher than that of a White adult of the same age. c. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight. d. A teenager's blood pressure reading will be lower than that of an adult.
A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days
The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A) Ask the patient's primary care provider to liaise between the nurse and the patient. B) Delegate care of the patient to a colleague. C) Limit contact with the patient in order to provide privacy. D) Make appropriate referrals to services that provide psychosocial support.
A nursing instructor is conducting a class on the different types of blood cells. Which of the following would the instructor include as the correct function? Select all that apply
A) Erythrocytes supply our cells with oxygen from the lungs to the tissues. B) Erythrocytes control bleeding from microscopic to major tears in our tissues. C) Leukocytes supply our cells with oxygen from the lungs to the tissues. D) Leukocytes protect the body from dangerous organisms. E) Megakaryocytes control bleeding from microscopic to major tears in our tissues.
What would be the nurse's next action with the following findings noted upon assessment of a client postarthroplasty: tachypnea, air hunger, hypoxia, O2 sat of 86%, decreasing mental status, and petechiae?
1. Prepare the client for immediate intubation and mechanical ventilation with PEEP. 2. Raise the head of the bed (HOB) and encourage coughing every hour. 3. Call a code for potential cardiac arrest situation. 4. Apply oxygen at 3 to 4 liters /minute and then call the health care provider.