During an examination, a nurse notes that there is a lesion on the client's upper back. What is the best way to document the size of this lesion?
a. Compare its size to the size of a coin.
b. Estimate its size to the nearest inch.
c. Use a centimeter ruler to measure the lesion.
d. Trace the lesion onto a piece of paper.
ANS: C
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The nurse reviews the laboratory results of a client and finds that the white blood cell (WBC) count is 1500/mm3 . What is the priority action of the nurse?
a. Have the client wear a mask at all times. b. Obtain a urine sample for culture and sen-sitivity. c. Administer two units of fresh-frozen plasma. d. Institute reverse isolation precautions.
A patient who was stabbed in the abdomen has received fluid resuscitation of 2 liters over the last hour. Which finding would the nurse evaluate as indicating this intervention has been ineffective?
1. Patient complaints of abdominal pain 2. Patient's request to see a priest 3. Urine output of 45 mL for this hour 4. Heart rate 142 and regular
Which of the following best describes one of the main problems in ensuring quality for health care in the United States?
a. Consumers believe American health care is high-quality and the best in the world. b. Every hospital and health care agency has its own approach to data collection and documentation. c. Finances are the basis of clinical decisions, not quality of care. d. We all agree on what quality is but not on how best to measure it.
The triage process in disaster involves
a. Separating the casualties and allocating treatment based on the victim's potential for survival b. Assignment of tasks to the appropriate disaster response personnel c. Determining the level of disaster and agency involvement d. Participating in mock disaster drills through realistic scenarios