A client returned to the nursing unit after having a nephrostomy performed. Over the next 6 hours, drainage in the tube has gone from 40 mL/hr to 12 mL over the last hour. Which interven-tion by the nurse is most appropriate?
a. Document the finding in the client's record.
b. Evaluate the tube as working in the hand-off report.
c. Clamp the tube in preparation for remov-ing it.
d. Assess the client's abdomen and vital signs.
D
The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should careful-ly assess the client's abdomen for pain and distention and check vital signs so that this informa-tion can be reported too. The other interventions are not appropriate.
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The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the "community" portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions?
a. "Do you believe in God?" b. "Are you a part of any religious or spiritual congregation?" c. "Do you consider yourself to be a religious or spiritual person?" d. "How does your religious faith influence the way you think about your health?"
A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:
a. Olecranon bursa. b. Annular ligament. c. Base of the radius. d. Medial and lateral epicondyle.
The nurse is conducting family planning with a healthy couple. The man's father had cystic fibrosis and his mother was healthy with no family history of the condition. The woman's family has no history of cystic fibrosis. Which is the most appropriate response for the nurse to make when asked about the risk of their child having cystic fibrosis?
A) All children will have cystic fibrosis. B) Each child has a 50% chance of cystic fibrosis. C) Each child has a 50% chance of being a carrier for cystic fibrosis. D) All children will be carriers for cystic fibrosis.
MC The Ottawa Charter for Health Promotion was significant for community health nursing practice because it
A. Focused on social, economic, and political reforms as strategies to improve global health. B. Identified assessment, policy formation, and assurance as key indicators for global health. C. Created specific mechanisms to categorize nursing services. D. Provided a mechanism for prospective payment for hospital services.