The nurse is doing a shift assessment on a 72-year-old patient with diabetes who has had a 2 pack/day smoking habit for 22 years. The nurse cannot palpate a dorsalis pedis pulse even with a Doppler
When reviewing previous assessment findings, they show that pulses were weakly palpable. What would be the first nursing action?
A) Notify the primary provider
B) Reevaluate the pulse again in 30 minutes
C) Reevaluate the pulse again in 15 minutes
D) Ask the patient how the extremity feels
A
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You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action?
A) You know that this patient will have a decreased level of consciousness. B) You know that this patient may not be motivated to prevent pressure ulcers. C) You know that the risk for pressure ulcers is directly related to the duration of immobility. D) You know that the risk for pressure ulcers is related to what caused the immobility.
A patient has been taking phentermine for 12 weeks for weight loss. The patient now reports that it no longer produces appetite suppression. The best action would be to:
a. switch to another agent in this class. b. discontinue the drug. c. increase the dose. d. continue the current dosing.
The nurse is caring for 4 clients with wounds and would ask that which client be evaluated further for negative-pressure wound therapy?
A. The client with a burned right arm that requires hydrotherapy three times a day for dressing changes. B. The client with a wound on the foot that is located near the toes. C. The client with a wound on the forearm who is malnourished due to anorexia from chemotherapy. D. The client with an abdominal incision that has not healed and is restricted to bed.
The experienced nurse assessing a battered woman client uses many open-ended questions during the interview. The rationale for this is that:
1. The woman will feel more in charge of the interview 2. Such questions allow for simple yes or no answers when the client is upset 3. The questions are direct and easily understood by anxious individuals 4. Clients can refuse to answer when sensitive information is being probed