The nurse is assessing a newly admitted patient with a pressure ulcer on the hip. Which clinical indicator does the nurse use to assess a stage II pressure ulcer?
a. Deep, open crater
b. Persistent redness
c. Boggy consistency
d. Superficial blistering
D
A stage II pressure ulcer is a superficial, partial-thickness skin loss presenting as an abrasion, blister, or shallow crater. A deep crater is consistent with clinical indicators for a stage III or stage IV ulcer. Persistent redness and a boggy or firm consistency are characteristics of a stage I pressure ulcer.
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The nurse notes a decrease in urine output to less than 25 mL/h and a decrease in blood pressure. These changes in patient condition may indicate:
A) Fluid volume overload B) Impaired gas exchange C) Decreased cardiac output D) Impaired cerebral circulation
The nurse is assessing the integumentary status of a patient diagnosed with chronic renal failure. Which of the following will the nurse most likely assess in this patient?
1. skin damp and mottled in color 2. skin pale with good turgor 3. skin flushed with poor turgor 4. skin dry, yellow-brown in color, with pruritis
A nurse is beginning a new position with a home-care agency that provides hospice care. The nurse learns that the primary role of the nurse providing hospice care is to
A. Provide for the patient's medical needs at the end of life. B. Help the patient stay active until their death. C. Assist the patient and family through the dying process and toward a good death. D. Provide hygiene and personal care when the family is unable to.
Which interventions should the nurse plan when caring for a child with a visual impairment (select all that apply)?
a. Touch the child upon entering the room before speaking. b. Keep items in the room in the same location. c. Describe the placement of the eating utensils on the meal tray. d. Use color examples to describe something to a child who has been blind since birth. e. Identify noises for the child.