The client has been started on Artane. The nurse notes that the client's bowel sounds are decreasing. What is the highest priority action on the part of the nurse?
a. Administer the drug; this is an expected reaction.
b. Administer the drug; this is an expected side effect.
c. Hold the drug; this is an adverse reaction to the drug.
d. Hold the drug; this is a life-threatening response.
ANS: D
A decrease in bowel sounds could signal the beginning of paralytic ileus.
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You are evaluating the plan of care for an older adult who is alcohol-dependent. Which patient documentation indicates the need for follow-up nursing interventions by the nurse?
a. Patient states that he intends to decrease his alcohol consumption. b. Patient arrives at his group session on time and well-groomed. c. Patient states, "I am an alcoholic because I drink 10 beers a day." d. Patient states that he understands that he needs continued treatment.
The client with neuropathic pain develops allodynia, which
a. can be relieved by daily doses of opioids. b. is a vague pain that is difficult for the client to describe. c. is pain due to a stimulus that does not normally cause pain. d. responds to NSAIDs taken several times a day.
A female patient is seen for "increased hoarseness" and "a change in voice quality." What is an appropriate assessment question for the nurse to ask this patient?
1. "What medications are you currently taking?" 2. "Have you recently had a cold?" 3. "Have you recently visited another country?" 4. "What is your occupation?"
Which should the nurse implement in a sterile field?
1. Flip sterile objects onto the sterile field. 2. Put fluid holders near edge of the field. 3. Wear sterile gloves to open sterile packs. 4. Open inner flaps of sterile packages first.