The nurse is caring for a patient who had a bone biopsy on the right leg. Which activity should the nurse implement?
a. Ambulate twice daily.
b. Monitor site of biopsy for bleeding.
c. Perform hourly passive range of motion.
d. Perform active range of motion every 2 hours.
ANS: B
After a bone biopsy the site should be monitored for bleeding. A. Ambulating may be indicated after it is determined that bleeding is not occurring at the site. C. D. Active or passive range of motion exercises should not be done until it is determined that bleeding will not occur at the site.
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The nurse remembers that which of the following clients typically responds emotively to pain?
1. Asian 2. Hispanic 3. Northern European 4. Non–English speaking
A female neonate has been in respiratory distress since delivery and is unresponsive to oxygen therapy. Endoscopy has confirmed a diagnosis of esophageal atresia and tracheoesophageal fistulae (EA/TEF)
Which of the following explanations should the care team provide to the infant's parents? A) "We will have to perform surgery to correct the hole in her throat to make sure that she is able to swallow and breathe normally." B) "This problem will require respiratory therapy and supplementary feeding, but it will likely resolve itself over time." C) "The biggest risk that your daughter will face until this is fixed is the danger of malnutrition and dehydration." D) "The priority in our immediate treatment prior to her surgery will be pain management, as the contents of her stomach can burn her lungs."
Auscultation of a child's heart reveals a loud murmur with no thrill. The nurse documents this as:
A) Grade II B) Grade III C) Grade IV D) Grade V
Which assessment finding of a client requires the nurse's immediate action?
a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw