A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following would the nurse do next?
A) Document this finding as normal.
B) Recheck in 5 minutes after elevating the arm.
C) Reassess after applying warm compresses.
D) Refer the client for medical follow-up.
A
You might also like to view...
A patient diagnosed with a primary immunodeficiency disorder has asked his siblings to be tested as possible stem cell donors. When discussing this procedure with his family, the nurse emphasizes that stem cells can be harvested from: Select all that appl
A) bone marrow. B) peripheral blood. C) skin tissue harvesting. D) mouth swabs. E) tears.
Three policemen bring a client to the mental health unit for admission
She had been directing traffic on a busy city street and shouting rhymes such as "to work, you jerk, for perks" and making obscene gestures at cars that came too close to her. When her husband was contacted at work, he reported that his wife had stopped taking her lithium 3 weeks ago and had not slept or eaten for 3 days, telling her husband she was "too busy.". When making an assessment, the two features characteristic of the disorder the nurse can identify are a. increased muscle tension and anxiety. b. cognitive deficit and low mood. c. poor judgment and hyperactivity. d. vegetative signs and poor grooming.
A nurse administers atenolol (Tenormin) to a client suffering an acute MI based on the understanding that this drug will result in which of the following changes in the client? Select all that apply
A) Increase the heart's excitability B) Decrease the heart's workload C) Increase the heart's oxygen consumption D) Decrease heart rate E) Constrict blood vessels
An older patient in a long-term care facility does not sleep much at night and prefers to stay up late reading. The patient takes "power naps" during the day. How should the nurse respond to this patient's plan to acquire adequate sleep?
1. Naps are sufficient to restore the missed sleep time. 2. Older people do not need as much sleep as younger adults. 3. Napping may simply contribute to the problem getting to sleep at night. 4. There is no problem as long as the total number of hours slept per 24-hour period is at least 8.