For intestinal tube placement the nurse should:
A. Remove the guide wire after the tube is inserted
B. Measure from the nose to the earlobe to the xiphoid process
C. Apply skin adhesive to the nose and anchor the tube with tape
D. Place the client on his or her right side until placement is confirmed with an x-ray film
C
C. Temporarily anchor tube to the nose with a small piece of tape, and check placement of tube.
A. Leave guide wire or stylet in place until correct position is ensured by x-ray film. Never attempt to reinsert a partially or fully removed guide wire or stylet while feeding tube is in place. This can cause perforation of the tube and injure the client.
B. Measure distance from tip of nose to earlobe to xiphoid process of sternum. Add additional 20 to 30 cm (8 to 12 inches) for NI tube.
D. Researchers indicate that placing the patient on the right side does not promote passage of the tube into the small intestine.
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A patient tells the nurse that she is afraid of getting cervical cancer because her mother died of cervical cancer. The most appropriate response by the nurse would be:
1. "You need to a have a pelvic examination every 6 months because of your histo-ry." 2. "If you have regular Pap smears, cervical cancer is usually diagnosed early and cured." 3. "There's no need to worry so much. Cervical cancer does not run in families." 4. "Cervical cancer is sexually transmitted. Don't switch partners often and you don't have to worry."
Expectant mothers should hear from their nurses that normal labor consists of all of the following except:
1. a single fetus presents by vertex. 2. it is completed within 8 hours. 3. regular progression of contractions, effacement, dilation, and descent. 4. No complications exist.
Which statement by a nurse is an example of nonjudgmental thinking?
a. "Hispanic-American patients live at the poverty level and don't have a chance." b. "Asian-American patients are unreadable. Nurses don't know what they're feeling." c. "Native-American patients could benefit from a lesson in assimilation." d. "Cultural diversity accounts for some African-Americans thinking illness is caused by a curse."
A clinical nurse coordinator is teaching a class of nursing students about surgical and postoperative care of the woman who undergoes cerclage. Which nursing student's statement indicates the need for further clarification of the teaching?
1. "Sometimes cerclage can be performed on an outpatient basis." 2. "If cerclage is performed emergently, the woman will usually be hospitalized for at least five days." 3. "If the woman's amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed." 4. "After 37 weeks' gestation, the woman's cerclage may be cut in order to allow for vaginal delivery."