Skin temperature is best assessed by the nurse using the:
A. Fingertips
B. Thumb and index finger
C. Palm of the hand
D. Dorsum of the hand
D
D. Using dorsum (back) of hand, palpate for temperature of skin surfaces.
A. Stroke skin surfaces lightly with fingertips to detect texture of skin's surface. Note whether skin is smooth or rough, thick or thin, tight or supple and if localized areas of hardness or lesions are present.
B. Assess skin turgor by grasping fold of skin on the sternal area or forearm with the fingertips. Release skinfold and note ease and speed with which skin returns to place
C. Palm of hand is not used to assess skin temperature. The dorsum of the hand is used.
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Consensual light reflex is examined when you shine your penlight into the right eye of a patient and then note the
a. pupillary reaction in both eyes. c. pupillary reaction in the right eye. b. pupillary reaction in the left eye. d. light reflected by the opaque lens.
A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN)
Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patient's urine output by UAP b. Administration of oral medications by LPN/LVN c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetes by RN who usually works on the pediatric unit
The government publication Healthy People 2020 describes the idea of the community/family health center as a provider of primary care for a large segment of the population, particularly underserved populations
Which of the following are focus area goals for this initiative? Select all that apply. A) Cancer B) Disability and secondary conditions C) Health care plans D) Diabetes mellitus type II E) Food safety F) Activities of daily living (ADLs)
The nurse caring for a client requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this client?
1. Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip 2. Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak 3. Assuring ventilator tubing is secured and does not pull on the client's airway 4. Verifying correct ventilator settings