A nurse is assessing a pressure ulcer on the heel of a 75-year-old male. She notes that the ulcer is deep, extending to the muscle and bone. How would the nurse stage this ulcer?
• Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling
• Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful
• Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallow
• Stage III pressure ulcers: Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present
The nurse is preparing for a wet-to-dry dressing change for a patient with a diabetic foot ulcer. What is the benefit of a wet-to-dry dressing for this patient?
The nurse is caring for a patient with hyperaldosteronism. The nurse notes some non-fatal cardiac rhythm changes on telemetry. What should the nurse do next?
A 13-year-old patient has been diagnosed with impetigo, caused by Staphylococcus aureus, for which he is receiving antibiotic treatment. While doing a physical assessment, the nurse would expect to find skin lesions on which of the following areas of the body?
The nurse administers vitamin B12 to a patient with pernicious anemia. This patient has the inability to absorb vitamin B12 because of a deficiency in:
The nurse is providing discharge instructions to a patient that underwent a thyroidectomy. Which of the following should be included in the discharge instructions?
A patient is admitted to the hospital with signs and symptoms of systemic lupus erythematosus (SLE). Which test would confirm the diagnosis?
A patient with benign prostatic hypertrophy is admitted to the hospital for a scheduled surgery. Which of the following surgeries is the least invasive?
A patient who recently underwent a kidney transplant is visited by a home health nurse. The nurse assesses the patient for transplant rejection. Which of the following would be present?
A 70-year-old patient diagnosed with testicular cancer has had testicular surgery. On the day of discharge the nurse gave him instructions and told him correctly that:
The nurse conducts a home visit for a patient undergoing chemotherapy due to leukemia. The health care provider reports the patient's neutrophil count is 600/mm³. Which instruction should the nurse provide the patient?
A patient who is to be discharged after being diagnosed with multiple myeloma is given instructions by the nurse. It is very important for the nurse to remind the patient to:
A nurse is assessing a patient suspected of an upper GI bleed. Which test should be used first to evaluate the patient's GI bleed?
An 82-year-old patient is having trouble maintaining regular bowel movements. The nurse is providing instruction and tells the patient to avoid:
Following a spinal cord injury, a patient undergoing rehabilitation is receiving instructions about urinary management. Which of the following is the most important for the nurse to tell the patient?
A patient with peptic ulcers is admitted to the hospital for a suspected perforation. While assessing the patient, the nurse would expect which common symptom of this complication?
The nurse is creating a care plan for a patient with idiopathic thrombocytopenia purpura (ITP), an autoimmune condition. Which of the following nursing interventions should be included?
A nurse is assessing a patient with acute pancreatitis. The nurse should be aware of which assessment findings that support the diagnosis?
A 57-year-old is admitted to an inpatient unit due to Crohn's disease. Which of the following should not be in the care plan?
A nurse is caring for a client diagnosed with testicular cancer who is receiving cisplatin intravenously. The nurse monitors the client for drug-drug interaction if which among the following are administered?
The nurse is planning interventions to protect a patient with thrombocytopenia. Which of the following interventions should be included?
A patient is admitted to the hospital due to a myocardial infarction. Which of the following interventions or devices would increase coronary perfusion and decrease cardiac workload?
A hearing impaired patient was admitted to the hospital. Which of the following is the best way for the nurse to communicate effectively?
A 69-year-old patient is set to have a cerebral angiogram through the femoral artery. Which of the following would the nurse include in the teaching?