The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue to evaluate:
a. treatment needed.
b. effectiveness of implementation.
c. whether improvement is occurring.
d. need for additional interventions.
C
Ongoing assessment of a pressure ulcer will evaluate whether improvement is occurring.
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The nurse is asked to shave a patient that is taking Coumadin. What is the most appropriate action?
a. Refuse to shave the patient because he is on an anticoagulant. b. Shave as usual with a safety razor. c. Offer to wax rather than shave the patient. d. Use an electric razor.
When performing a neurovascular check, a nurse should do which of the following? Select all that apply
1. Ask the patient if he or she is experiencing numbness, burning, or tingling in the affected limb. 2. Test sensation of the affected and unaffected limbs by touching each with a paper clip. 3. Ambulate the affected limb to check for mobility. 4. Ask the patient to move the fingers or toes of the affected extremity. 5. Test capillary refill in the nailbeds of the fingers or toes distal to the surgical site or cast.
The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. Which is the priority nursing diagnosis for this child?
1. Hypothermia related to decreased metabolic state 2. Acute Pain related to the effects of a congenital heart defect 3. Ineffective Tissue Perfusion (peripheral) related to cyanosis secondary to congenital heart defect 4. Impaired Gas Exchange related to pulmonary congestion secondary to the increased pulmonary blood flow
Which medication is an example of an antidiarrheal?
A. Metamucil B. Ducolax C. Colace D. Imodium-AD