The nurse is caring for a patient with a traumatic injury to the abdomen who is prescribed conservative, non-operative management
Which ongoing assessments should the nurse include in the plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hourly vital signs
2. Assessment of the degree and type of guarding or rigidity
3. Hourly CVP readings
4. ECG changes for bradycardia and widening QRS
5. Widening pulse pressure
1,2,3
Rationale 1: This would be done in the patient with a traumatic abdominal injury to assess for peritonitis.
Rationale 2: This would be done in the patient with a traumatic abdominal injury to assess for peritonitis.
Rationale 3: This would be done to assess fluid status and the onset of hypovolemic shock in the patient with a traumatic abdominal injury.
Rationale 4: The ECG will show tachycardia from hypovolemia. Widening QRS show slowed conduction in the ventricles and would not be a sign of abdominal distress.
Rationale 5: Widening pulse pressure is not seen in the patient with traumatic abdominal injury.
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A supervisor is reviewing the documentation of the nurses in the unit. The documentation that most accurately and correctly contains all the required parts for a narrative entry is the entry that reads:
1. "1630 Catheterized using an 8 French catheter, 45 ml clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mother's arms following catheter removal. M. May RN" 2. "1/9/05 2 P.M. g-tube accessed, positive air gurgle over stomach: 5 ml air injected, 10 ml residual stomach contents returned to stomach, Pediasure formula hung on Kangaroo pump infusing at 60 mL/hr for 1 hour. Child grunting intermittently throughout procedure. K. Earnst RN" 3. "4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. F. Luck RN" 4. "Feb. '05 Portacath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gammaglobulins hung and infusing at 30mL/hr. Child smiling and playful throughout the procedure. P. Potter, RN"
Which of the following statements is true regarding the average child's growth and development?
A. A child's weight typically triples at a year B. A child's weight typically quadruples by age 2 C. During the puberty growth spurt, females gain approximately 38 pounds D. All of the above
Which of the following are valid nursing interventions in treating schizophrenic patients? (SELECT ALL ANSWERS THAT APPLY)
A) Do not reinforce hallucinations, delusions, or illusions. B) Provide a stimulating environment for the patient. C) Keep communication simple. D) Promote the patient's problem-solving skills. E) Emphasize behavior that is appropriate to the situation. F) Encourage the patient to confront stressful situations.
The nurse is planning care for a client diagnosed with hypercalcemia caused by hyperparathyroidism. Which of the following should the nurse add as interventions to this client's care plan? (Select all that apply.)
1. Administer high volume intravenous fluids as prescribed. 2. Monitor arterial blood gases. 3. Calculate sodium chloride intake to achieve 400 mEq each day. 4. Provide low rates of intravenous fluids. 5. Provide thyroid replacement medication orally. 6. Monitor body temperature.