Which of the following assessment data would indicate compromised gastrointestinal function?
A)
Increased appetite
B)
Semisolid and moist stool
C)
Clay-color stool
D)
Bowel sounds active in all four quadrants
C
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The nurse is preparing the necessary supplies to change a client's large abdominal wound dressing
In deciding which supplies are necessary, the nurse reviews the purpose of the client's bandage, including: Standard Text: Select all that apply. 1. Securing a dressing. 2. Protecting the skin. 3. Preventing injury. 4. Padding the skin surfaces. 5. Applying pressure.
A nurse is caring for a client with a musculoskeletal disorder who is experiencing a significant impairment in the ability to ambulate due to pain. As a result, the client spends a majority of time in bed
Which of the following would the nurse most likely include in the client's plan of care? A) Changing the client's position every 2 hours B) Changing the bed linens every hour C) Encouraging the client to walk with assistance D) Encouraging the client to exercise with assistance
Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective?
a. Assess for the presence of a paradoxical pulse. b. Monitor for changes in the patient's sedimentation rate. c. Assess for the presence of jugular venous distention (JVD). d. Check the electrocardiogram (ECG) for ST segment changes.
The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best choice of nursing diagnosis problem statements for this family?
1. Anticipatory Grieving 2. Dysfunctional Grieving 3. Hopelessness 4. Caregiver Role Strain