Stage II pressure sores are the most traumatic and life threatening
Indicate whether the statement is true or false
False
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An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first?
a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.
A nurse is caring for an obese patient who has been bedridden for a long time and who has a nursing diagnosis of "Risk for infection, related to obesity
" Where is the best location for the nurse to assess for the moist red lesions of Candida albicans? a. Scalp, behind the ears b. Abdominal skin folds c. Shaft of the penis d. Sacrum and bony prominences
For a client with deep vein thrombosis (DVT), the nurse would include in the plan of nursing care the intervention of
a. applying cool compresses to the area. b. maintaining the legs in the dependent position. c. raising the foot of the bed 6 inches. d. restricting fluids.
A patient is going to have a cardiac procedure that requires moderate sedation. The nurse is explaining to the patient what is included in the pre-sedation assessment
Which statement(s) in-dicates the nurse has a good understanding? (Select all that apply.) a. "Have you arranged for someone to drive you home after the procedure?" b. "How frequently do you drink alcohol?" c. "Have you had any problems with anes-thesia before?" d. "Do you have any drug allergies?" e. "Do you currently use any drugs? How frequently have you used drugs in the past?" f. "Is there a family history of drug use or abuse?"