A nurse is reviewing a patient's chart and notes a Braden score of 14. The nurse understands that this score corresponds with what level of pressure ulcer risk?
• In the Braden scale, there are six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
• Scores range from 6-23 with a total score of 10 or less representing a high risk.
• Very high risk: Less than 10
• High risk: 10-12
• Moderate risk: 13-15
• Mild risk: 16-23
• Sensory perception is scored from completely limited-1, very limited-2, slightly limited-3, and no impairment-4.
• Moisture is scored from constantly moist-1, often moist-2, occasionally moist-3, and rarely moist-4.
• Activity is scored from bedfast-1, chairfast-2, walks occasionally-3, and walks frequently-4.
• Mobility is scored from completely immobile-1, very limited-2, slightly limited-3, and no limitations-4.
• Nutrition is scored from very poor-1, probably inadequate-2, adequate-3, and excellent-4.
• Friction and shear
A community health nurse is giving health education to the members of a community regarding breast self-examination (BSE). During the educational session, a patient verbalized something that the nurse needs to correct. Which of the following statement indicates the need for further teaching?
A patient with heart failure (HF) due to systolic dysfunction is being educated by the nurse on angiotensin-converting enzyme (ACE) inhibitors. The nurse should include which of the following in the discharge teaching?
The nurse is caring for a patient with venous insufficiency that has developed varicose veins. Which of the following statements about varicose veins is accurate?
What members of the health care team should be consulted for a patient with a stage II sacral ulcer?
A nurse is assessing multiple skin lesions on a patient with pemphigus vulgaris. The skin is easily rubbed off when the nurse applies slight friction. This best describes which of the following?
A nurse is reviewing a patient's electrocardiogram (EKG) and notes that the T waves appear inverted. The nurses suspect which of the following as the most likely condition?
While caring for a patient who underwent a percutaneous transluminal coronary angioplasty (PTCA), the nurse prepares to remove the femoral sheath. The heparin infusion was stopped 4 hours ago and there appears to be no evidence of bleeding from the insertion site. In order to prevent bleeding complications, the nurse will pull the sheath when the activated partial thromboplastin time (aPTT) is
A nurse is providing instructions to a patient with contact dermatitis. Which of the following interventions can be used to reduce pruritus and burning?
Nurses can expect which of the following interventions to help regulate or treat patients with atrial flutter?
A burn patient returns from surgery with an autograft on the left elbow. Which of the following steps should the nurse take to improve skin graft outcomes?
A nurse is caring for a client with fluid overload. The nurse knows that the typical findings in a client with fluid excess include which of the following?
The nurse is caring for a patient who sustained multiple fractures and a spinal injury from a motor vehicle accident. Which nursing intervention is most important when caring for this patient on bedrest?
While reviewing an electrocardiogram (EKG), the nurse knows that the "P" wave represents which of the following?
The nurse is preparing to defibrillate a patient with ventricular fibrillation. The nurse should double check the synchronizer switch because
A home health nurse is caring for a patient with intermittent pruritus with no underlying pathological process. To reduce the severity of this problem, the nurse should instruct the patient to:
The nurse is providing interventions to a patient with a deep vein thrombosis (DVT). Which of the following interventions should be avoided?
A nurse is instructing a nursing student on performing a 12-lead electrocardiogram (EKG). Which statement made by the nursing student indicates correct understanding of the precordial lead placement?
The nurse is performing a physical assessment on a patient who underwent a total knee replacement. Which of the following findings requires the nurse to notify the physician?
The nurse is providing pre-procedure education to a patient scheduled to undergo cardiac catheterization. Which of the following statements should the nurse include?
The nurse is encouraging a patient with peripheral artery disease (PAD) to start a progressive exercise program. The nurse explains that exercise will improve symptoms of intermittent claudication because exercise will
A patient recently had an implantable cardioverter-defibrillator (ICD) inserted. The patient expresses concern about the device discharging during sexual activities and shocking the patient's spouse. The nurse should explain that
As part of a comprehensive cardiovascular examination, the nurse palpates the apical pulse. At what location should the nurse palpate?
The nurse is assessing the crutches of a 27-year-old with a fractured ankle. The crutches are fitted properly if:
A patient with hypothyroidism is three days post-operative knee replacement when the patient becomes confused with marked hypothermia, and myxedema coma is suspected. What immediate actions should the nurse include?
The nurse is assessing a patient with a stable abdominal aortic aneurysm (AAA). The nurse should suspect an extending aneurysm if which finding is noted?
A patient with a history of multiple pulmonary emboli is scheduled for an inferior vena cava (IVC) filter placement. The nurse explains to the patient that the purpose of an IVC filter is to
A patient is admitted with fluid overload. What clinical manifestations can the nurse expect to notice?
A patient returns to the unit after a cerebral arteriogram. Which of the following interventions will the nurse perform?
A patient is being discharged after a bilateral nephrectomy. The patient will perform peritoneal dialysis at home. Which of the following best promotes continuity of care?
The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS). To evaluate for early signs of Kaposi's sarcoma, the nurse assesses the patient for lesions that are
A patient presents with generalized lymphadenopathy, anorexia, an extra-nodal mass, and Waldeyer ring involvement. What type of lymphoma is this?
The nurse is preparing a care plan for a patient with polymyositis. The nurse understands that the patient is at an elevated risk for
In order to rule out laryngeal cancer, the physician performed direct visualization of the patient's larynx. Which of the following should the nurse tell the patient to do so that there will be a reduced sensation of gagging during the procedure?
A nurse preceptor is watching her student prepare a patient for hemodialysis. Which of the following should the nurse preceptor stop the student from doing?
The nurse is educating a patient with cirrhosis about lifestyle changes. Which of the following statements by the patient indicates the need for additional education?
A 53-year-old male patient is scheduled to undergo an endoscopic retrograde cholangiopancreatography (ERCP). The nurse performs an assessment on the patient prior to the procedure. Which of the following health background information from the patient should alert the nurse?
A patient with acute back pain is admitted to the hospital. The physician orders magnetic resonance imaging (MRI) of the spine and a physical therapy consult for back strengthening. In what sequence should the nurse schedule the orders?
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?
The nurse is providing colostomy education to a patient prior to discharge. The nurse knows that the patient did not understand the instructions when he states:
The nurse is providing care for a patient admitted due to a thyroid storm. The nurse performs a comprehensive physical assessment and is most likely to discover which of the following?
The nurse is caring for a patient with accelerated silicosis. With this type of silicosis, the nurse would expect
The nurse is providing dietary instructions to a patient with hypothyroidism. The nurse should encourage the patient to consume a diet