The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.)
a. Paleness
b. Transparent skin
c. Superficial scalp veins
d. Vomiting
e. Bulging fontanelles
ANS: A, D, E
Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent skin and superficial scalp veins are expected findings.
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a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles
The nurse caring for a patient with hepatic encephalopathy assesses that the patient exhibits episodes of confusion, is difficult to arouse from sleep, has rigid extremities, and EEG abnormalities
Based upon these clinical findings, what is the patient's stage of hepatic encephalopathy? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4
Which of the following is a primary intervention? Choose all that apply
1) Immunization for meningitis of college-bound students 2) Safer sex education for high school students 3) Lobbying for health education in the schools 4) Tuberculosis screening via PPD testing
A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude?
It will help the manager to: a. Consider all the possible advantages and disadvantages b. Maintain an open mind about the proposed change c. Apply the Nursing Process to the situation d. Make a decision based on past experience with documentation