Answer to Question 1
ANS: B
The nurse needs to assess the patient's skin. Assessment should not be delegated; it is the responsibility of the licensed registered nurse. The nurse needs to document the assessment findings objectively, not subjectively, per the nursing assistive personnel. Before requesting a consult or determining treatment, the nurse needs to assess the skin.
Answer to Question 2
ANS: A
If the staff member's performance is not satisfactory, give constructive and appropriate feedback. You may discover the need to review a procedure with staff and offer demonstration. Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. Telling that catheter care is sloppy does not correct the problem. The catheter does not need to be removed.
The nurse conducts the health history as the first step in the nursing assessment
Nursing hand offs
Nursing assessment questions
Patient teaching: heart assessment
Palpation for tactile fremitus using metacarpophalangeal joint area
Round your answer to the nearest tenth. A patient with a pulmonary embolus has Refludan ...