The nurse assesses a patient with a pressure ulcer. Which assessment datum does the nurse use to support the identification of a stage III pressure ulcer?
a. Nonblanching and reddened areas of in-tact skin
b. Extensive destruction of the skin and muscle
c. Full-thickness skin loss from the surface down to the bone
d. Full-thickness skin loss from the surface down to the fascia
D
A stage III ulcer involves damage or necrosis of subcutaneous tissue extending down to, but not through, the fascia. A nonblanching area of reddened skin is a stage I pressure ulcer. Stage IV pressure ulcers are full-thickness ulcers involving extensive tissue destruction and necrosis of subcutaneous tissue, fascia, muscle, and bone.
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The highest therapeutic blood range for antibiotics is determined at the _____ of the blood level
a. peak b. trough c. weight d. dilution
A client with schizophrenia tells the nurse "I eat skiller. Tend to end. Easter. It blows away. Get it?"
The best response for the nurse to make would be a. "Nothing you are saying is clear.". b. "Your thoughts are very disconnected.". c. "Try to organize your thoughts and then tell me again.". d. "I am having difficulty understanding what you are saying.".
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L
Should the nurse start salt tablets when caring for this client? A) Yes, this will correct the sodium deficit. B) Yes, along with the hypotonic IV. C) No, start with the sodium chloride IV. D) No, sodium intake should be restricted.
Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives
The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which of the following would be an example of assisted suicide? A) Administering a lethal dose of medication B) Administering a morphine infusion C) Granting a patient's request not to initiate enteral feeding when the patient is unable to eat D) Neglecting to resuscitate a patient with a "do not resuscitate" status