A nurse observes yellow-tinged sclera on a client with dark skin. Based on this observation, what is the nurse's best action?
A. Examine the soles of the client's feet.
B. Nothing; this is a normal finding in all people with dark skin.
C. Inspect the client's oral mucosa and hard palate for other indications of jaundice.
D. Notify the physician of the possibility that the client has a liver or hemolytic dis-order.
C
Jaundice can best be observed in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Because sclera may have subconjunctival fat deposits that show a yellow hue and foot calluses may appear yellow, neither of these areas should be used to assess for jaundice.
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The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. b. A thorough history and physical assessment information should be obtained from the patient's family member. c. A complete history and physical assessment should be immediately performed to obtain baseline information. d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved.
A nurse wishes to increase an at-risk child's resilience. What action by the nurse would be most helpful?
A. Assist the child in recognizing internal resources. B. Help the child see that others are worse off. C. Instruct the child to "toughen up." D. Teach the child therapeutic communication skills.
A sulfonamide, Bactrim, is ordered for a patient with a urinary tract infection. What should the nurse teach the patient to do while taking this medication?
a. Drink large amounts of water with this medication. b. Take the medication on a full stomach. c. Take the medication at night before going to bed. d. Drink milk when taking the medication.
When the nurse delegates measurement of vital signs to unlicensed assistive personnel (UAP), which are the nurse's responsibilities?
1. Assessment of vital sign readings obtained by UAP 2. Assessment of the UAP's skills in measuring vital signs 3. Determination that the vital signs were obtained correctly 4. Follow up on vital sign measurements that are abnormal or unexpected 5. Observe the UAP as vital signs are being measured