A patient's catheter bag is empty 2 hours after it was last drained. The nurse's first action is to:
a. Irrigate the catheter
b. Perform a bladder scan
c. Replace the catheter
d. Check for kinks or compression
D
Kinks or compression of the catheter or tubing may impede flow of urine into the bag. If there are no kinks or compression, assessment for urinary retention by performing a bladder scan may be appropriate. Irrigating the catheter and replacing the catheter are more invasive interventions that increase the patient's risk for infection. These options may be considered after a full assessment is completed and no other, simpler cause is identified.
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When the patient asks what the purpose of goniometry is, the nurse replies that goniometry measures:
a. bone strength. b. muscle density. c. muscle strength. d. range of motion.
The nurse tells the client that alkylating agents kill cancer cells by:
1. containing substances from bacteria that can kill cancer cells. 2. disrupting critical cellular pathways of cancer cells. 3. changing the shape of the DNA double helix and preventing DNA from duplicating during cell division. 4. blocking substances necessary for continued growth of tumors.
A patient reports using "homeopathic remedies" to ease her back pain. In order to more fully explore the patient's use of complementary and alternative medicine (CAM), the nurse should ask:
1. "Will you tell me more about the homeopathic remedies you're using?" 2. "Are you aware that some complementary and alternative therapies can be dangerous?" 3. "Does your physician approve of your use of homeopathic remedies?" 4. "Have you prioritized your need for comfort above your concern for your baby's health?"
Janet Rogers works in a shelter for homeless persons in a large city. One Thursday, Janet cared for Derrick, a 3-year-old who is currently living in a car with his parents and older brother. Because of her experience,
Janet knows that Derrick should be thoroughly assessed because homeless children are at risk for: 1. Childhood cancers, substance abuse, delays in motor skills, and malnutrition. 2. Incomplete immunization, respiratory disorders, anemia, and developmental delays. 3. Physical and sexual abuse, gastrointestinal abnormalities, and lead poisoning. 4. Tuberculosis, AIDS, hepatitis B, and mental illnesses.