What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool?
a. Assess for abdominal distention.
b. Decrease the amount of the next feeding.
c. Institute enteric precautions.
d. Get a culture of the next stool.
ANS: A
Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.
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An older patient suffering from chronic exhaustion has an EEG that shows little time is spent in REM sleep. After reviewing the patient's history, what does the nurse suspect might be contributing to the patient's sleep problem?
A) Has two or three glasses of wine near bedtime B) Obese and diagnosed with type 2 diabetes 6 years ago C) Takes low-dose aspirin for the prevention of heart disease D) Stressed due to the spouse's new diagnosis of Alzheimer disease
The nurse receives report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?
A) The patient admitted with acute renal failure B) The patient admitted following a myocardial infarction C) The patient admitted with malignant hypertension D) The patient admitted following a stroke
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to your unit. You would be correct in assessing for what adverse effect of this therapy?
A) Bradycardia B) Diarrhea C) Gingivival hyperplasia D) Weight gain
The nurse is trying to determine if a patient is a refugee. Which characteristics would the patient need to fulfill in order to be classified as a refugee? Select all that apply:
1. The person is outside the country of nationality. 2. The person is unable to return to the country of nationality because of persecution. 3. The person is unable to return to the country of nationality because of fear of persecution. 4. The person is outside of the country of last habitual residence. 5. The person is naturalized and owes allegiance to the United States.