A patient has areas of petechiae and ecchymosis over the arms and legs. The nurse would document this assessment finding within which section of the nutritional physical assessment?
A) Cardiovascular and peripheral vascular
B) Skin, hair, and nails
C) Musculoskeletal
D) General survey
A
You might also like to view...
The nursing care plan for the client with a diagnosis of Chronic Pain should always include: Standard Text: Select all that apply
1. Establishing a client–nurse relationship. 2. Client teaching. 3. Considering the client's ability and willingness to participate. 4. Using distraction. 5. Presenting choices.
The nurse is gathering the necessary equipment for tracheal intubation for a child who is 2 years old. Which tracheal tube size would the nurse obtain?
A) 4.5 B) 5 C) 5.5 D) 6
What body has been established to protect participants of research?
a. Institutional review board b. State board of nursing c. Nursing research board d. Peer review panel
On postoperative day 2, R.O. continues to improve and is tolerating ice chips. Breath sounds are clear, and
she is performing her pulmonary hygiene. NGT has minimal drainage. The Foley catheter and Penrose drain have been removed, and her urine output is adequate. Her IV line is saline locked. The incision is well approximated with no drainage or redness. Her pain is 4 to 6 out of 10 with pain medication every 4 hours. Later that evening your assessment shows that R.O. is pale and listless; bowel sounds are absent; abdomen is distended and tender to the touch; the NGT is draining an increased amount of dark, green- ish black fluid. Her lung sounds are moist bilaterally, and her temperature has spiked to 40.2 ° C (104.4 ° F), O2 saturation is 97% on room air. she rates her pain at 10 out of 10 and is having difficulty taking deep breaths because of the pain, which she says "hurts over my whole stomach." What actions would you take?