Height and weight measurements are essential at every health care visit for clients in all age groups because these measurements:
a. document that basic client evaluation has been done
b. provide data related to maturational level
c. indicate the need for diagnostic follow-up
d. signal possible onset of alterations that may indicate illness
D
At the outset of the examination, the nurse obtains the client's vital signs (temperature, pulse, respirations, blood pressure) and height and weight. The nurse should be familiar with usual or normal findings in each aspect of the head-to-toe assessment for each client, such as the normal range of values in the vital signs of an infant or an older adult or the expected skin turgor at different developmental stages. Alterations from the normal ranges could indicate illness.
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The nurse is caring for a patient who is taking medication that is toxic to the liver. Which laboratory test results will be reviewed by the nurse to ensure that the patient's liver is tolerating the medication without damage to the organ?
(Select all that apply.) a. Alanine aminotransferase (ALT) b. Alkaline phosphatase (ALP) c. Blood urea nitrogen (BUN) d. Anti-nuclear antibody (ANA) e. Erythrocyte sedimentation rate (ESR) f. Fibrin degradation products (FDP)
The LPN is supervising the nursing unit staff when a nonlethal breach in client standards of care occurs. Which situation demonstrates the limitations of supervising client care in the role of the LPN?
A) The LPN supervisor is unable to write the incident report outlining the breach in care standard. B) The LPN supervisor reports the breach in care standard to the RN only. C) The LPN supervisor oversees the staff but has no disciplinary responsibility. D) The LPN supervisor is responsible for personal care and not all nursing functions.
What is the purpose of the grounding electrode??
A) To capture any heart irregularities B) To capture any arrhythmias C) To measure heart muscle activity D) To reduce electrical interference from outside of the body
The nurse understands that which statements regarding BP and the BP requirement are true? SELECT ALL THAT APPLY
a. The highest pressure is the systolic pressure; the lowest pressure is the diastolic pressure b. The pt should be in a comfortable lying or sitting position when taking the blood pressure c. Maximum BP is created in the arteries when the right ventricle pushes blood into the aorta d. The difference between systolic pressure and diastolic pressure is known as pulse deficit e. The point on the gauge where the 1st faint but clear sound appears is known as diastolic pressure