After completing a scheduled every 2-hour turn by turning the patient to the left side, the nurse notices a reddened are over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area:
a) Reactive hyperemia
c) Stage II pressure ulcer
d) Stage III pressure ulcer
Ans: a) Reactive hyperemia
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The patient is receiving a beta-receptor antagonist medication. What is the most significant effect on cardiac function that the nurse should be monitoring for?
A) Decreased cardiac output B) Supraventricular tachycardia C) Increased stroke volume D) Increased blood pressure
The nurse includes in postoperative care for a patient with reimplantation of the right thumb the implementations of:
1. decreasing the temperature of the room to 70ºF. 2. elevating the hand, but keeping it below the level of the heart. 3. offering coffee, tea, or cola to help increase fluid intake. 4. placing an antiembolus sleeve on the right arm.
Which diagnosis would be considered the priority nursing diagnosis for the client with Guillain-Barré syndrome?
A. Ineffective Breathing Pattern related to skeletal muscle weakness B. Risk for Injury, Impaired Skin Integrity related to immobility C. Self-care Deficit related to skeletal muscle weakness D. Anxiety related to powerlessness
The nurse is caring for a client with renal insufficiency. The diuretic of choice for this client is:
a. spironolactone. c. triamterene. b. furosemide. d. acetazolamide.