The nurse is ready to begin a tube feeding via a nasogastric feeding tube for a patient who is comatose. Which action should the nurse take?
a. Lay the patient supine.
b. Elevate the head of the bed 10 degrees.
c. Place the patient in high Fowler's position.
d. Place the patient onto the left side with knees flexed.
ANS: C
When feedings are administered, patients must be positioned in a sitting or high Fowler's position to reduce the risk of aspiration. A. B. D. These positions increase the patient's risk of aspiration.
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A client returns to the nursing unit after laporoscopic surgery. The nurse prepares to take the client's vital signs at several intervals, including:(Select all that apply) Standard Text: Select all that apply
1. Every 15 minutes for first hour 2. Every 30 minutes for second and third hours 3. Every hour for fourth through seventh hours 4. Every 30 minutes for three hours 5. Every four hours from return from surgery
The perinatal nurse describes the need for an assessment for deep vein thrombosis in the postpartum patient. The test is described as:
A) Homans' sign: extended legs, flexed knees followed by dorsiflexion of the foot B) Homans' sign: flexed legs, flexed knees followed by foot extension C) Chadwick's sign: extended legs, flexed knees, followed by dorsiflexion of the foot D) McBurney's sign: flexed legs, flexed knees followed by foot extension
From the structural or functional framework, what does the nurse know that all communities must do?
A. Address financial needs of residents. B. Engage in functions that can be measured. C. Provide for socialization and a sense of identity. D. Require specific structures (police and fire stations) be built.
When the nurse shines a light in a patient's left pupil, both of the pupils constrict. What type of response should the nurse document?
a. Direct b. Abnormal c. Consensual d. Accommodation ____