The nurse is assessing the skin of a client being admitted to the long-term care facility from an acute care facility. A small blister is noted on the client's right heel. This is documented as:
1. A stage I decubitus ulcer.
2. A stage II decubitus ulcer.
3. A stage III decubitus ulcer.
4. A stage IV decubitus ulcer.
Question 2
The nurse is admitting a 79 year-old client to a long-term care facility, whose daughter is on her way to visit. The nursing care plan might include which of the following: Standard Text: Select all that apply.
1. Risk for Ineffective Individual Coping
2. Family expresses understanding of problems
3. Situational transition
4. Secretions are mobilized
5. Risk for Impaired Parenting
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
Pulse oximetry with the sensor probe applied securely, flush with skin, making sure that both sensor
A port fuel-injected engine that is equipped with long, tuned intake-manifold runners.
Testing the Achilles tendon reflex with client in a supine position
Skin