When reading a TB test the practical nurse measures the mm of?

A nurse is orienting a newly licensed practical nurse about documentation of a client’s information in the electronic health record.  Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

The client has a 2-piece colostomy appliance. After removing the client’s colostomy pouch to inspect the stoma and skin wafer, the nurse notices a dark shadow under the skin wafer. What is the best nursing action to implement in response to this finding? 

A client is receiving a morning Insulin injection supplied in an Insulin Pen. The client received yesterdays morning dose in the abdomen.  Determine the technique that safely administers this medication.

Choose the best position for catheterization to use with a confused, 95 year old female resident.

The nurse assesses a client’s blood pressure and obtains two consecutive readings of 152/92 and 156/94.  These readings correspond with which clinical guideline?

A nurse may see which neurological variation in geriatric adults? 

The nurse understands the appropriate way to document pulses that are weak and diminished?

A client is in droplet precautions for a diagnosis of pertussis (whooping cough). Which of the following interventions should the nurse implement?  Choose the best answer.

The nurse is caring for a client who has a nasogastric Salem Sump tube connected to low continuous suction for decompression. Which of the following interventions should the nurse implement?