Answer to Question 1
ANS: A
The nurse needs to assess the patient's skin. Assessment should not be delegated; it is the responsibility of the licensed professional nurse. The nurse needs to document the assessment findings objectively, not subjectively per the nursing assistant. Before requesting a consult or determining treatment, the nurse needs to assess the skin.
Answer to Question 2
ANS: C
The nurse needs to intervene if observing the technician taking an oral temperature after consuming any type of beverage because of the potential for a temperature difference in the liquid that may affect the patient's measured temperature. The other options are appropriate.
Landmarks of the Area Around the Mouth
Closed urinary drainage system. Urine being measured after it leaves patient’s body via catheter.
Cystostomy. An artificial opening is made through the urinary bladder wall during this procedure. As
Nursing intervention classification 2
Nursing Interventions and Prochaska's Stages of Change
The popliteal area. Avoid heavy pressure over the back of the knee joint.