A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance? Select all that apply
A) Check for presence of bowel sounds
B) Assess temperature
C) Check gastric residual by aspirating stomach contents
D) Assess stools
A
Check for presence of bowel sounds
C
Check gastric residual by aspirating stomach contents
D
Assess stools
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What trend in healthcare has only existed for the past decade and has changed nursing education to prepare student nurses for practice after graduation?
1. Technology 2. Cultural diversity 3. HIV 4. Nursing shortage
A client has a chronic wound that is being treated with a vacuum-assisted wound closure (VAC) device. Which intervention by the nurse takes priority?
a. Provide pain medication as needed. b. Assess the VAC every 2 hours for bleed-ing. c. Check the integrity of the dressing seal every 4 hours. d. Document the wound size with each dressing change.
The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action?
A. Administer oxygen. B. Loosen the dressing. C. Notify the emergency team. D. Document the observation as the only action.
A nurse asks a patient to remember the following object, color, and address: pencil, red, and 15 Maple Street. After 15 minutes the nurse asks the patient to repeat the object, color, and address. The nurse is assessing:
a. judgment. b. recent memory. c. ability to abstract. d. immediate recall.