A nurse is assessing the sacral pressure ulcer of a 89-year-old patient. The nurse notes that the skin is not intact and the wound bed appears pink with serum fluid. How would the nurse stage this ulcer?
• Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallow
• Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful
• Stage III pressure ulcers: Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present
• Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling
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 give the patient?
A nurse is caring for a client with left hemiparesis after a right-sided ischemic stroke. Which of the following would the nurse do to prevent skin breakdown and contractures from disuse on the left side?
The nurse visits a patient who was discharged after receiving chemotherapy for the treatment of colon cancer. Upon assessment, the nurse found that the patient developed stomatitis. Which of the following should the nurse remind the patient to avoid?
A nurse is caring for a patient who suffered a right-sided CVA. Which of the following would the nurse expect to see?
The nurse is caring for a patient with Guillain-Barré syndrome. The patient states that they want to die rather than live with the disease. Of the following, which is an appropriate response?
A nurse is caring for a patient diagnosed with myasthenia gravis. When caring for this patient, which of the following interventions are appropriate?
The nurse is assessing a client for complications resulting from a femur fracture. Which of the following support a diagnosis of Fat Emboli Syndrome (FES)?
A hearing impaired patient is admitted to the hospital. Which of the following is the best way for the nurse to communicate effectively with this patient?
A patient came into the emergency room after hitting his head on the floor during a basketball game. The nurse is obtaining a Glasgow Coma Score on the patient. The score is as follows:
Best Eye Opening = 3
Best Motor Response = 6
Best Verbal Response = 4
Total GCS = 13
The nurse interprets these findings as
A patient has been diagnosed with a concussion and is now being released from the hospital. Which of the following should the nurse include in the discharge instructions?
A patient diagnosed with leukemia underwent a bone marrow transplant. Which of the following are specific interventions for post-transplant nursing care?
A patient is seen in the emergency department after a bee sting caused bronchospasm and severe pruritis. The nurse understands that this type of hypersensitivity reaction is known as
A 49-year-old male with chronic renal failure will be starting hemodialysis. The nurse understands that hemodialysis is necessary for the patient because of the following:
The nurse is admitting a patient suspected of having Goodpasture's syndrome. The nurse should be alert for signs of damage to which organs?
The nurse suspects that a patient has developed a deep vein thrombosis (DVT). Which of the following tests would gather more evidence in support of this diagnosis?
While obtaining the patient's vital signs, the nurse notes that the patient's heart rate is 136. Which of the following cardiac effects will likely result from the patient's elevated heart rate?
What are the appropriate nursing actions to promote adequate gas exchange for a client with acute decompensated heart failure (ADHF) and unknown cardiac status?
A patient diagnosed with infiltrating ductal carcinoma of the breast is admitted to the oncology unit. Which of the following manifestations would the nurse expect to find during the assessment of the patient?
The nurse is caring for a patient with a left arm cast. The nurse should be alert for the following when assessing for signs of infection:
A patient with aortic regurgitation is seen in the clinic for a regular
A client diagnosed with left-sided heart failure has decreased cardiac output related to altered contractility. Which of the following nursing actions are appropriate for improving cardiac pump effectiveness?
A nurse is caring for a newly admitted patient following a burn injury. The nurse suspects an inhalation injury. Which of the following assessment findings would support the nurse's suspicion?
The nurse is writing a care plan for a client with symptomatic Paget’s disease. Which of the following interventions should be included to help the patient's symptoms?
A patient with burn injuries has a carbon monoxide level of 45%. The nurse would expect which of the following based on this carbon monoxide level?
The nurse is educating a patient recently diagnosed with muscular dystrophy. When explaining the normal course of this disease, the nurse should know that the patient:
The nurse is caring for a dehydrated client with impaired oral mucous membranes related to lack of oral intake and vomiting. What nursing interventions should be included in the care plan to relieve symptoms?
A nurse is caring for a client with a gout flare-up. Which of the following indicate appropriate care?
The nurse is assisting the physician with the application of a cast to a 27-year-old with a fractured ankle. Which of the following instructions takes priority?
An adolescent with leukemia asked the nurse what carcinogens are. The nurse correctly answers the patient by explaining that carcinogens are factors associated with cancer risk such as
A patient diagnosed with multiple myeloma was treated with cyclophosphamide. Which of the following interventions should be included in the nursing care plan?
The nurse is reviewing the biopsy report. The physician's conclusion is that the patient has a benign neoplasm. Which of the following best describes the characteristics of a benign neoplasm?
A 48-year-old female with Addison's disease is admitted to the hospital. When assessing the patient, the nurse would expect
A patient with multiple