The nurse performing the Aldrete scoring system must assess: (Select all that apply.)
a. activity.
b. circulation.
c. presence of wound drainage.
d. level of consciousness.
e. O2 saturation.
A, B, D, E
The Aldrete scoring system requires that the nurse assess activity, circulation, respiration, level of consciousness, and oxygen saturation.
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A critically ill patient is admitted with a leukocyte count of 18,000 per cu. mm of blood. The nurse realizes this count is
A) normal. B) high. C) low. D) life-threatening.
Which of the following would the nurse identify as a goal for a client who is receiving an antiviral drug? Select all that apply
A) Adverse reactions are identified and treated. B) Adequate nutritional status is maintained. C) Perceptions of body changes are managed successfully. D) Skin integrity is successfully maintained. E) Therapeutic response is achieved.
A client with darkly pigmented skin reports that the intravenous site is "uncomfortable." To thoroughly assess the complaint of this particular client, the nurse should:
1. Determine when the angiocatheter was inserted 2. Ask the client if the area appears reddened 3. Take an axillary temperature on the same side as the IV site 4. Use the back of the hand to assess skin temperature at the site
The nurse is explaining the difference between active and passive immunity to the student nurse. Which statement accurately describes a characteristic of the process of immunity?
A) Active immunity is produced when the immunoglobulins of one person are transferred to another. B) Passive immunity can be obtained by injection of exogenous immunoglobulins. C) Active immunity can be transferred from mothers to infants via colostrum or the placenta. D) Passive immunity is acquired when a person's own immune system generates the immune response.