A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding?
A) Erythema
B) Pallor
C) Petechiae
D) Ecchymosis
A
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The nurse should document this finding as erythema. If the skin appears pale, it is documented as pallor. The presence of purple patches on the skin, due to trauma to soft tissue, is documented as ecchymosis. Petechiae are small red or purple spots on the skin.
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A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?
a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time
A client is on a 1200-mL fluid restriction for 24 hours. At breakfast and lunch, the client consumed 3/5 of the fluid allowance. How many milliliters did the client consume?
A) 280 B) 360 C) 540 D) 720
List four reasons why the AV junction may assume responsibility for pacing the heart
What will be an ideal response?
A nurse manager is educating unit staff on cultural competence. The manager knows that the teaching has been effective when one of the staff members states that cultural competence is (Select all that apply.)
a. "not important in health care.". b. "accepting and respecting cultural differ-ences.". c. "demonstrating knowledge of the patient's culture.". d. "demonstrating an understanding of the patient's culture.". e. "adapting care to be congruent with the patient's culture.".