A nurse performing an integumentary inspection on a patient gently pinches the skin under the clavicle. This nurse is assessing:
A) Skin texture
B) Skin moisture
C) Skin turgor
D) Skin vascularity
C
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A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.v
The nurse is assessing a toddler when the child's mother states that the child has had a fever for the past two days
When the nurse asks the mother what the temperature has been, the mother replies that she hasn't actually taken it but the child's skin has felt very warm. Which response by the nurse is appropriate in this situation? 1. "When our skin feels warm, it means our blood vessels are constricted." 2. "The only reliable indicator of body temperature is by feeling the forehead." 3. "Our skin temperature changes when our surroundings change temperature." 4. "The temperature of the skin is not related to what is happening inside our bodies."
A patient recovering from a lung transplant will have denervation of the lung tissue. What should the nurse include when planning this patient's care?
Select all that apply. 1. administering mucolytics every 2 hours 2. performing postural drainage twice a shift 3. ensuring oxygen delivery is below 2 liters 4. scheduling deep breathing and coughing every 2 hours 5. positioning for chest vibration and percussion twice per shift
Who is protected by state laws when an employed nurse provides care to a client?
a. The health care provider and the client b. The agency or hospital and the client c. The health care provider and the agency or hospital d. The client and the general population