A nurse is assessing the wound in the left arm of a client. The wound, caused by a motor vehicle accident, has torn, ragged edges. How should the nurse document the wound in the electronic medical record?
A) Incision
B) Abrasion
C) Laceration
D) Puncture
C
Feedback:
A wound with torn, ragged edges should be documented as a laceration. An incision is a wound with clean edges. Abrasion is the rubbing off of the skin's surface. A puncture is a deep stab wound.
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The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patient's level of consciousness (LOC)?
A) Assess the patient's vital signs and correlate these with the patient's baselines. B) Assess the patient's eye opening and response to stimuli. C) Document that the patient currently lacks a level of consciousness. D) Facilitate diagnostic testing in an effort to obtain objective data.
A new nurse on the orthopedic floor makes a medication error. Which statements by the nurse manager foster a safe environment in which nurses will report medication errors?
1. "Many of us have made a medication error in our careers. The most important issue is to identify why the error occurred." 2. "I know you could not feel any worse than you already do. We need to discuss how this error happened and how we can prevent it from happening again." 3. "It's really good that your patient is OK and did not suffer any harmful effects of this error. We should discuss why this error occurred and how it can be prevented in the future." 4. "Because you are a new nurse, we should sit down and discuss the procedure you followed to see what you could have done to prevent this error." 5. "We need to sit down as soon as possible and write up an incident report describing everything you did incorrectly that caused this error."
A young mother is concerned her 2-year-old daughter is gaining too much weight. Which of the following should the nurse recommend the mother give daily when following a 1000 cal/day diet? Select all that apply
A) 1 cup vegetables D) 4 oz grain B) 2 cups dairy E) 1/2 cup fruit C) 2 oz protein F) 3 cups dairy
A life-threatening condition is recognized with the assessment of:
a. pain with downward pressure on both an-terior superior iliac spines. b. guarding and intense pain with deep pal-pation of the abdomen. c. distant and muffled heart sounds, with distended neck veins. d. severe throbbing pain in one eye, with photophobia.