A client has a stasis ulcer on the left ankle. Nursing assessment of this open area involves which skin assessment parameter?
a. integrity c. turgor
b. moisture d. vascularity
A
Skin should be intact (integrity) with no evidence of tissue injury; the nurse should note any broken skin or open areas, and the color, size, and location of any rashes or lesions such as nodules or pustules.
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A patient with a steadily increasing preload was experiencing a corresponding increase in stroke volume, but it has now begun to decrease. Which rationale would the nurse provide for this occurrence?
1. This fluctuation will occur until maximum preload has been reached. 2. The patient's heart rate is increasing, which causes a drop in stroke volume. 3. The patient's preload has reached a critical point and now stroke volume will decrease. 4. It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease.
Which technique should a nurse use in performing the Rinne tuning fork test?
A. Start the fork vibrating and place the stem on the mastoid process. When the client no longer feels the vibration, move it in front of the pinna and ask the client to indicate when sound is no longer heard. B. Start the fork vibrating and place the stem on the mastoid process. When the client no longer hears sound, move it in front of the pinna and ask the client to indicate when sound is no longer heard. C. Start the fork vibrating, hold the fork in front of the pinna, and ask the client to indicate when sound is no longer heard. Then place the stem on the mastoid process and ask the client to indicate when he or she no longer feels the vibration. D. Start the fork vibrating, hold the fork in front of the pinna, and ask the client to indicate when sound is no longer heard. Then place the stem on the mastoid process and ask the client to indicate when he or she no longer hears the sound.
The nurse admits the client to the hospital after a motor vehicle accident 2 hours ago. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Explain the client's current condition to the family. 2. Ask the client to provide details about the accident. 3. Check for an analgesic on the provider's prescriptions. 4. Report the client's vital signs to the nurse immediately.
During a patient care conference, the HCPs are reviewing potential outcomes based on individual interventions. Which bioethical theory is being demonstrated during this care conference?
a. Religion b. Deontology c. Theological d. Utilitarianism