As part of R.L's admission assessment, you conduct a skin assessment. What areas of R.L.'s
body will you pay particular attention to?
What will be an ideal response?
The first area to assess is the known right-sided pressure ulcer. You would then assess all other bony
prominences because they are vulnerable to pressure or decubitus ulcers. Examine in skinfolds and
the perianal area for candidiasis (yeast and intertrigo). Examine the skin and take pulses below the
knees because she has a history of peripheral vascular disease.
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A patient is receiving methylergonovine (Methergine) after a vaginal birth. What assessment finding by the nurse warrants immediate intervention?
A. Headache B. Nausea C. Palpitations D. Uterine cramping
The nurse is asked by the spouse of a patient seeking crisis intervention to give an example of an adventitious crisis. The nurse should mention:
a. the death of a child from sudden infant death syndrome. b. being fired from one's job because of company downsizing. c. the retirement of a 64-year-old man after 30 years' service. d. a riot at a rock concert that results in multiple casualties.
Which of the following best defines a tethered PHR?
1. A tethered PHR is inextricably linked to a single entity or health system. 2. A tethered system is a stand alone system. 3. A tethered system can be found on a thumb drive. 4. A tethered system cannot access a patient portal.
A nursing executive wishes to implement a new policy based on initial National Patient Safety Goals 2002 to eliminate wrong patient, wrong site, and wrong procedure. Which action by the executive would best meet one of the goals?
a. Collaborate with the laboratory for timely reporting of laboratory values. b. Formulate a time-out policy. c. Mandate that all fall-prone patients be clearly identified. d. Reevaluate work flow design and patient–staffing ratios.