D.s. continues to complain of abdominal pain and cramping and becomes increasingly restless. Younotice that the abdomen behind and around his stoma and pouch appears larger when compared withthe other side of his abdomen
How would you assess for a possible peristomal hernia?
Have the patient lie flat, supine. Uncover the abdomen so that the belly and stoma are visible. Then
ask the patient to tuck his chin to his chest, raising his head off of the bed. A hernia manifests as a
bulge or protrusion. You might also note a "swelling" of the area when the patient is standing. Notify
the physician or ostomy nurse if a hernia is suspected.
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Before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72 beats/minute. Which is the best action for the nurse to take?
A) Hold the digoxin. B) Recheck the apical pulse in 30 minutes. C) Administer the digoxin. D) Notify the physician.
A child with meningococcemia is being admitted to the pediatric intensive care unit. This child should be placed in a:
1. Semi-private room. 2. Private room, but not in isolation. 3. Private room, in protective isolation. 4. Private room, in respiratory isolation.
Which of these blood pH values is an indicator of alkalosis?
1. 7.80 2. 7.40 3. 7.35 4. 6.98
What safety measures should a nurse teach/encourage for school-age children?
1. Have a gate blocking access to the stairs 2. Wearing a helmet when riding a bicycle as well as a helmet and pads for rollerblading 3. Always check mirrors before starting to drive 4. Keep sharp objects out of reach