The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the entire assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items are not the first items used.
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Some cultures see personal touching as an insult unless you are intimately related. In the secondary health care setting, the need for touching to administer care may produce what within the patient?
a. Cultural strain b. Impaired functioning c. Cultural insult d. Increased self-care deficit
A nurse has delegated the task of ambulating a patient to two nursing assistants. Despite the patient's appearance, assistance of two people is needed for safe ambulation. The nurse discovers the patient being ambulated by only one aide
What should be the nurse's first action? 1. Demand to know why a second aide is not assisting with this patient. 2. Assist the aide in completion of the ambulation. 3. Scold the second aide for not carrying through with the delegated task. 4. Immediately initiate disciplinary actions against both aides for not following directions.
The nurse is assisting the physician during a colonoscopy procedure. The nurse helps the client to assume which of the following positions for the procedure?
1. Left Sims 2. Lithotomy 3. Knee chest 4. Right Sims