The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate?*1 pointa. Notify the physician.b. Examine dependent body areas.c. Assess turgor on the client's forehead.d. Document the finding and continue to monitor.

A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?A. Document the finding and continue with routine careB. Apply a topical antibiotic ointment to the affected areasC. Conduct and document an emergency assessmentD. Perform and document a focused assessment of skin integrity

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?A. Clear items from the client's surrounding area.B. Lower the client to the floor.C. Obtain the client's vital signs.D. Loosen the client's restrictive clothing.

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?A. Monitor the client's vital signs once every hour.B. Elevate the head of the client's bed to a 45° angle.C. Restrict the client's fluid intake.D. Instruct the client not to bend the affected leg.

A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take?

The nurse is caring for a client experiencing hypovolemic shock. Which of thefollowing interventions would not be appropriate for this client? ***(a) Monitor intravenous fluid replacement.(b) Monitor vital signs(c) Monitor hemoglobin and hematocrit levels(d) Assist to a sitting position