In assessing a pressure ulcer on a client’s hip, which action should the nurse include? Determine the degree of elasticity surrounding the lesion Photograph the lesion with a ruler placed next to the lesion Stage the depth of the ulcer using the Braden numeric scale Use a gloved finger to palpate for tunneling around the lesion
Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion. A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client’s plan of care? Implements decisions about future hospices services within the next 3 months. Marinating pain level below 4 when implementing outpatient pain clinic strategies. Request home health care if independence become compromised for 5 days. Arranges for short term counseling stressors impact work schedule for 2 weeks. Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also the client has a terminal disease and is being discharge home, hospice and health care are not indicating at this time. Short term counseling is not an option. 452. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image). A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? Auscultate all quadrant of the abdomen. Perform a digital rectal exam Palpate the liver and spleen Obtain a hemoccult of the client’s stool The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating A paced rhythm with 100% capture after pacemaker replacement Normal sinus rhythm and complaining of chest pain Atrial fibrillation with congestive heart failure and complaining of fatigue Sinus tachycardia 3 days after a myocardial infarction A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement? Complete pre-infusion checklist The nurse is evaluating the health teaching of a female client with condyloma acuminate.
- Fall '19
- Nursing, UAP, male client