A nurse inspecting a patient's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
C
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Which of the following is a valuable tool that is used for planning and judging the progress of the program evaluation?
a. Conceptual framework b. Review of the literature c. Instrument development d. Calendar of events
When counting respirations, you should
A) do this without the patient being aware that you are counting respirations. B) tell the patient what you are going to do. C) count five respirations and then check your watch. D) have the patient count respirations while you take his/her pulse.
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?
a. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. b. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. c. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. d. The nurse elevates a leg cast when the patient reports decreased mobility.
A nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while she was working as a nursing assistant
What advice is best for the nursing faculty member to give to the nursing student? a. "Just be careful when you are doing new procedures and make sure you are following directions by the nurse." b. "Review your procedures before you go to work, so you will be prepared to do them if you have a chance." c. "The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened." d. "You are not allowed to perform any procedures other than those in your job description even with the nurse's permission."