A patient hourly urine output is recorded. Which of the following output rates should be brought to the attention of the registered nurse immediately?
a. 15 mL/hr
b. 40 mL/hr
c. 60 mL/hr
d. 80 mL/hr
ANS: A
Urine output should be 30 mL/hr, so 15 mL/hr should be reported.
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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"
Although there is great benefit in using technology to facilitate communication for clients and health-care providers, nurses need to be aware of associated legal issues
Indicate whether the statement is true or false
If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to
a. Take the blood pressure. b. Massage the fundus. c. Notify the physician or nurse-midwife. d. Place the woman in Trendelenburg position.
The nurse is taking a report of the assigned clients for the day. One client is a 27-year-old practicing Hindu. When the breakfast tray is delivered, it is noted that there is bacon on it
What would be the most culturally sensitive action to take? A) Take the tray to the client and do not worry about it. B) Send the tray back to the kitchen and ask for a lacto-ovo vegetarian diet tray. C) Take the tray into the client's room and ask what he wants to do. D) Remove the bacon from the plate and serve the tray to the client.