The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as:
A) Decorticate posturing
B) Nystagmus
C) Doll's eye
D) Sunsetting
D
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What is the priority nursing diagnosis for an 89-year-old patient with frequent liquid stools?
A) Imbalanced nutrition: less than body requirements B) Deficient fluid volume C) Deficient knowledge related to medications D) Pain related to abdominal cramping
The nurse is caring for an older adult client with an ileostomy and hemiplegia secondary to a stroke experienced a few years ago. When changing the client's one-piece appliance, the nurse finds the skin under the skin barrier is ulcerated and erythematous
The client does not empty the pouch until it is completely full because it hurts so much to remove the skin barrier. Which action by the nurse is the priority? 1. Apply a two-piece ostomy appliance. 2. Treat the damaged skin and replace the one-piece pouch. 3. Keep the skin open to air to allow time for healing, and replace the ostomy appliance in a few days. 4. Call the health care provider to report the damaged skin.
Which backup EHR downtime application is critical to avoid disrupting nurses' care of patients?
a. The billing system b. The registration system c. CPOE and the MAR (medication administration record) d. the SAN (storage area network)
The nurse is teaching a client about home care after cataract surgery. Which statement indicates that the client requires further teaching?
a. "I am glad that I don't need an eye patch after the surgery." b. "I will try a cool compress to decrease the swelling around the operated eye." c. "Dark sunglasses will be necessary when I am in the sun." d. "Pain, nausea, and vomiting are normal after this surgery."