A nursing assistant reports seeing a reddened area on the ...

[tnt_battle]

A nursing assistant reports seeing a reddened area on the patient's hip while bathing the patient. The nurse should
 
  a. Go to the patient's room to assess the patient's skin.
  b. Document the finding per the nursing assistant's report.
  c. Request a wound nurse consult.
  d. Ask the nursing assistant to apply a dressing over the reddened area.

Question 2

A nurse observes a patient care technician using all these measures when taking vital signs. Which measure requires the nurse to intervene?
 
  a. Palpates brachial artery before inflating blood pressure cuff
  b. Counts respirations while palpating radial pulse
  c. Inserts thermometer into sublingual pocket after patient sips water
  d. Asks patient to relax arm before taking blood pressure

[trog]

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.