An 80-year-old resident prefers to lie in bed on her left side. The nurse anticipates that the risk for skin breakdown is greatest over which area?
a. Left buttock
b. Left heel
c. Left trochanter
d. Left ribs
C
The areas that are most prone to break down in the immobile patient are over bony prominences.
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The nurse is assessing an older patient's risk for developing problems while hospitalized for an acute illness. The Hospital Admission Risk Profile (HARP) tool will be utilized. Which assessment areas would alert the nurse to a risk? Select all that apply.
1. Age of 87 2. Manual dexterity score of 14 3. Cognitive function score of 7 4. Ability to self-feed score of 2 5. Independence IADL's score of 5
Victims of a house fire are being admitted through the emergency department. Of the patients, the nurse realizes that which will have the greatest general risk for mortality from the burn injuries?
1. 25-year-old pregnant female 2. 49-year-old male who smokes 3. 75-year-old female with arthritis 4. 50-year-old male with coronary artery disease
While assessing the client at risk for shock, a nurse finds the client's systolic blood pressure to be 20 mm Hg lower than baseline. What is the nurse's best first action?
A. Increase the IV rate. B. Administer oxygen. C. Notify the physician. D. Document the finding as the only action.
The nurse clarifies that the medication montelukast (Singulair) is a leukotriene modifier, which helps the asthmatic patient:
a. Liquefy and cough up mucus b. Obtain quick relief from an acute asthma attack c. Prevent or lessen the severity of an asthma attack d. By providing bronchodilation