J.O. has a Foley catheter inserted to drain his urine. What would you assess for in relation to
the Foley catheter?
What will be an ideal response?
• High-speed accidents can result in acceleration-deceleration injuries to the kidneys. The kidneys
should produce 30 to 60 mL of urine per hour.
• High-speed accidents frequently result in some degree of crush injuries to muscles. With a crush
injury, rhabdomyolysis can occur because of the breakdown of skeletal muscle fibers with leakage
of muscle contents (e.g., myoglobin) into the circulation. The excess myoglobin can damage
the renal tubules, causing acute kidney injury. It is critical to order a series of daily urinalyses
(UAs) looking for the presence of blood, myoglobin, and creatinine kinase until a stable UA is
established.
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Nursing roles associated with shifts in the delivery of psychiatric services to social and community settings would not include:
1. Leading community support groups for couples receiving genetic counseling. 2. Providing case management as part of an interdisciplinary team. 3. Participating as a member of a community board for social planning activities. 4. Providing individual therapy in a private practice setting.
A community health nurse is responding to a disaster. Which of the following would most likely be the least appropriate area for the nurse to be?
A) The disaster site B) Triage C) Victim treatment area D) Local hospitals
A night shift nurse who has returned from maternity leave is much stressed. The nurse has difficulty focusing on her tasks. Which of the following would apply to the nurse?s level of stress? Select all that apply
1. Family problems related to different shift schedules 2. The physiological stress adjusting to the shift 3. A change in the family dynamics 4. Being married 5. Assistance from other nursing staff
A nurse teaching a student nurse how to remove a nasogastric tube discusses interventions to be performed in unexpected situations. Which of the following statements accurately describes one of these interventions?
A) If within 2 hours after NG tube removal, the patient's abdomen is showing signs of distention, notify the physician. B) If within 2 hours after NG tube removal, the patient's abdomen is showing signs of distention, replace the NG tube. C) If epistaxis occurs with removal of the NG tube, occlude one nare until bleeding has subsided. D) If epistaxis occurs with removal of the NG tube, ensure that patient is in a lying position.