The nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet. What is the most appropriate nursing action?
a. Report this sign immediately.
b. Place a warm towel over the extremities.
c. Gently sponge with cool water.
d. Medicate for pain.
ANS: D
A purple flush indicates the return of sensation and causes extreme pain.
You might also like to view...
A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month
Which of these statements or questions is the nurse's best response in this situation? a. "Do you have a weapon?" b. "How do other people treat you?" c. "Are you feeling so hopeless that you feel like hurting yourself now?" d. "People often feel hopeless, but the feelings resolve within a few weeks."
A patient has been brought to the emergency department by ambulance after sustaining major burns in a house fire
The nurse would anticipate that which therapies have been initiated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Jewelry has been removed. 2. Ice bags have been applied to burned areas. 3. The burn has been covered with a clean sheet. 4. Tetanus prophylaxis status has been determined. 5. Burn ointment has been applied to all partial-thickness burns.
The nurse is caring for an older patient recovering from a bleeding ulcer. Which manifestations should the nurse use to determine whether the patient is experiencing peritonitis?
Select all that apply. 1. confusion 2. bradycardia 3. restlessness 4. abdominal discomfort 5. decreased urinary output
After teaching environmental control to the parents of a child with asthma, the nurse determines that teaching was successful when the parents make which of the following statements?
1. "We will replace the carpet in our child's bedroom with tile.". 2. "We're glad the dog can continue to sleep in our child's room.". 3. "We'll be sure to use the fireplace often to keep the house warm in the winter.". 4. "We'll keep the plants in our child's room dusted.".