The nurse is performing a physical examination on a sleeping newborn. Which of the following body systems should the nurse examine last?
A) Heart
B) Abdomen
C) Lungs
D) Throat
D
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If the infant is asleep, the nurse should auscultate the heart, lungs, and abdomen first while the baby is quiet. The nurse performs the assessment in a head-to-toe manner, leaving the most traumatic procedures, such as examination of the ears, nose, mouth, and throat, until last.
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The nurse caring for the patient with an ileostomy will include special interventions to prevent skin breakdown and irritation at the stomal site because the:
a. large adhesive patch for the collection bag is irritating. b. ileostomy stoma is very large and difficult to cover completely with the adhesive fa-ceplate. c. liquid stool from the ileum contains diges-tive enzymes that are especially harmful to the skin. d. soft stool is difficult to remove from the skin without abrading the skin.
A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
A) no problem B) possible problem C) actual problem D) clinical problem
A nurse uses informatics to plan nursing care for a patient. Which three terms best describes this science as it is applied to nursing?
A) data, information, knowledge C) research, controls, variables B) process, documentation, analysis D) hypothesis, nursing, practice
A nurse administers medications to older adults in a long-term care facility. Which of the following actions is most appropriate when the client with dementia is newly prescribed an antimuscarinic agent for urge urinary incontinence?
A) Administer with a full glass of water B) Assess the client for drooling and diarrhea C) Monitor the client closely for worsening cognitive impairment D) Toilet the client before administering the medication