A patient with darkly pigmented skin is on bed rest and is being assessed for a possible stage I pressure ulcer. What datum about the area of concern will best help the nurse determine the cor-rect staging assessment?
a. The skin will be slightly broken.
b. The skin color is darker than surrounding tissues.
c. The tissue is the same temperature as sur-rounding tissues.
d. The skin blanches easily.
B
Early detection of pressure ulcers for a patient with dark skin is problematic because initial skin changes are difficult to distinguish. Characteristics of impaired skin integrity for patients with dark skin include changes in skin color, especially skin darkening or areas of purplish or bluish tones as cells begin to exhibit clinical indications of hypoxia. If the skin is already broken, the patient is not "at risk" but rather has a skin integrity issue. The tissue can be warmer or cooler than adjacent tissue. Blanching may not be visible in a person with darkly pigmented skin.
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The nurse is caring for a client who has seizure precautions. Which actions by the nurse are appropriate for these precautions?
Select all that apply. 1. Padding the bed around the head, foot, and side rails 2. Placing functional oral suction equipment in the room 3. Placing extremity restraints in the room for use if the client has a seizure 4. Keeping pillows handy to protect the client's head 5. Taping a bite block to the wall to protect the client from biting his or her tongue
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A. Release the traction on the catheter. B. Obtain an order to remove the current catheter, allowing the client to void spon-taneously. C. Tell the client that the large size of the catheter makes him feel the urge but that the catheter is draining properly. D. Irrigate the catheter with 50 mL of normal saline every hour until the urine is no longer blood-tinged or filled with debris.
According to established standards, which health care provider should conduct a holistic assessment for all clients admitted to the hospital?
A) Physician B) Admission clerk C) Licensed practical nurse D) Registered nurse