The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action?
a. Pink and warm to the touch
b. Pale and cool to the touch
c. Dark pink and dry to the touch
d. Pink and slightly moist to the touch
B
The skin flap should appear pink in a light-skinned person and not discolored in a darker-skinned person. The area should feel warm but not hot. Pale and cool skin could indicate inadequate blood flow to the area. The nurse would notify the provider.
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A nursing student is learning about the effects of bactericidal agents. How does rifampin (Rifadin) achieve a therapeutic action against both intracellular and extracellular tuberculosis organisms?
A) It is metabolized in the liver. B) It binds to acetylcholine. C) It inhibits synthesis of RNA. D) It causes phagocytosis.
What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with ulcerative colitis?
a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers
A nurse is preparing a client to undergo cardiac catheterization. What specific assessment should the nurse make before the procedure?
A. Ascertain if the client will require sedation. B. Ascertain if the client is able to roll side to side. C. Ascertain if the client has a history of diabetes mellitus. D. Ascertain if the client has allergies to iodine-containing substances.
A patient with depression has taken an SSRI for 1 month. The nurse should use direct questions to evaluate which potential side effect?
a. Aggressive impulses b. Sexual dysfunction c. Paranoid delusions d. Weight gain