Upon assessing the client in the morning, the nurse notes that there is urine leaking out around the indwelling urinary catheter. The nurse should first:
A. Insert the catheter farther
B. Reinflate the catheter balloon
C. Remove the catheter and reinsert another
D. Apply padding around the urinary meatus
B
B. Leakage of urine from around catheter indicates improper catheter placement, possible balloon deflation, or too small a catheter. Reinflate balloon or replace catheter.
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A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?
a. Assesses the client's pain level per agency policy b. Monitors the client's respiratory rate and sedation c. Presses the button when the client cannot reach it d. Reinforces client teaching about using the PCA pump
A patient has a permanent pacemaker and complains of redness and swelling over the site of the generator implantation. The patient also has fever and leukocytosis. What is the most appropriate nursing action?
A) Assess for any patient action causing pressure on the site. B) Assure the patient that these are signs of normal healing. C) Ensure that pacemaker is working correctly. D) Facilitate administration of intravenous antibiotics.
The nurse is teaching a class for newly hired cardiac care nurses and is discussing dronedarone (Multaq). What statement, if made by the nurse, is accurate? (Select all that apply.)
A) "Dronedarone has properties of all four classes of antiarrhythmics." B) "Dronedarone reduces the risk of hospitalization in patients in atrial fibrillation." C) "Dronedarone has many drug–drug interactions that need to be reviewed." D) "It is an oral drug taken once a day." E) "Common adverse effects of dronedarone include ventricular arrhythmias."
A 12 year old comes in with her mother and has the following symptoms: a 40.0 C fever, chills, coughing, and chest pains. Her mother states that she just finished Amoxicillin for strep throat and her chest x-ray shows consolidation
Based on these findings, what would be possible nursing interventions to manage this patient? 1. Monitor oxygenation status and results of sputum culture, CBC, PTT, and sweat chloride test from the laboratory 2. Monitor respiratory, oxygenation, and hydration status and give antibiotics as ordered 3. Monitor respiratory and oxygenation status and give pneumococcal vaccine injection as ordered 4. Monitor oxygenation and hydration status and inform mother that antibiotics would be ineffective for her daughter