ATI RN Fundamentals Exam Review Questions & Answers-Integumentary and peripheral vascular systems: identifying types of lesions
List two (2)
... [Show More] examples of a primary skin lesion including description and example of each. Provide an example of appropriate documentation of the integumentary system. - Macule: Nonpalpable, skin color change, < 1 cm. Example: Freckle
Papule: Palpable, circumscribed , < 0.5 cm. Example: Elevated nevus
Nodule/tumor: Palpable, circumscribed, 0.5 cm or >. Example: Wart
Vesicle: Serous fluid-filled, < 1 cm. Example: Blister
Pustule: Pus-filled. Example: Acne
Wheal: Palpable, irregular borders, edematous.
Example: Insect bite
EXAMPLE: Skin is pink, warm, and dry. Turgor is brisk and skin is elastic. Rough, thickened skin over heels, elbows, and knees; otherwise, skin is smooth. A 0.5 cm brown papule on right forearm and a 2.5 cm scar on left knee that is healed. Capillary refill is < 3 seconds. No edema is noted.
Airway management: Discharge teaching regarding Home Oxygen Therapy
A client is receiving home oxygen. What teaching points should the nurse provide the client and the caregiver regarding home oxygen safety? - Since oxygen is combustible, the following nursing actions are important for the nurse to implement:Post ""No Smoking"" or ""Oxygen in Use"" signs to alert others of the fire hazard. Know where to find the closest fire extinguisher. Educate about the fire hazard of smoking with oxygen use. Have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity. Ensure that all electric devices (razors, hearing aids, radios) are working well. Make sure all electric machinery (monitors, suction machines) is grounded. Do not use volatile, flammable materials (alcohol, acetone) near clients receiving oxygen.
Nursing Process: Priority Action When Providing Care for a Newly Admitted Client
The assistive personnel reported to the charge nurse that a client's vital signs are as follows:
Blood Pressure 148/72, Pulse 92, Respirations 30, Temperature 102° F
What action should the nurse take? - The nurse should reassess the client's vital signs to validate the data collected by the assistive personnel.Assessment and data collection is the first and important part of the nursing process. Assessment/data collection involves the systematic collection of information about clients' present health statuses to identify needs and additional data to collect based on findings. Nurses can collect data during an initial assessment (baseline data), focused assessment, and ongoing assessments. Without first completing the appropriate client assessment, the nurse would not be able to formulate the correct plan of care for the client.
Nursing Process Documenting the Implementation Step of Client
List three (3) actions by the nurse shoul [Show Less]