A pt with a PE is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform?
a. measure abdominal girth because the med causes fluid retention
b. check skin turgor because dehydration contributes to anticoagulation
c. monitor for N/V, and diarrhea
d. Examine skin every 2 hours for evidence of bleeding
Answer: d. Examine skin every 2 hours for evidence of bleeding
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The nurse is assessing a newborn. The parents are present. Which statement is best?
1. "Your infant was born with several reflexes. Some help her eat and protect her. I will show you what they look like." 2. "You will be most successful if you put your baby to breast when she has her eyes wide open and she is looking around." 3. "The muscle tone of your baby will increase as she gets older. You'll notice her head lagging less in a few weeks." 4. "The umbilical cord stump will dry up and fall off in about two weeks. There might be a spot of blood when it falls off."
The hospice nurse instructs caregivers in repositioning the patient because the patient spends most of the time reclining, which can lead to:
a. contractures. b. pressure ulcers. c. bruising. d. excoriation.
What is the main purpose of documentation in the medical record?
1. It is used to communicate patient condition to the health care team. 2. It records patient information for future research studies. 3. It verifies the dates of patient admission. 4. It ensures all charges are validly documented for third party payers.
The nurse is documenting the teaching plan for a client. What should be included in this documentation?
1. Actual information to be taught. 2. Teaching strategies to use. 3. Skills to be taught. 4. Amount of time needed to teach each topic. 5. Vital signs before and after each teaching session.