When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?
a. Urinary catheter care
b. Nasogastric (NG) tube feeding
c. Continuous cardiac monitoring
d. Maintain a warm room temperature
e. Administration of H2 receptor blockers
ANS: A, C, D, E
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine.
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A theory of communication that emphasizes the three ways to communicate—hearing, seeing, and touching—is called _________________________
ANS:
A woman you care for in a prenatal clinic tells you that her pregnancy was unplanned and unwanted. At what point in pregnancy does the average woman change her mind about an unwanted pregnancy?
A) Around the third month B) When quickening occurs C) After lightening happens D) After the seventh month
The nurse is giving a report to the oncoming ICU shift for the most recent admission. The nurse indicates the patient is hypotensive, has an S3 heart sound, has crackles, has pink frothy sputum, and the skin is diaphoretic and cool
The oncoming shift recognizes which differences between cardiogenic pulmonary edema (CPE) and noncardiogenic pulmonary edema (NCPE)? 1. NCPE patients are hypotensive, have an S3 heart sound, and have a cough. 2. CPE patients are hypotensive, have an S3 heart sound, and have dry skin. 3. NCPE patients are hypertensive, have bounding pulses, and have jugular vein distension (JVD). 4. CPE patients are hypotensive, have an S3 heart sound, and are cool and diaphoretic.
The nurse is preparing to reconstitute a medication in a multiple-dose vial. The nurse correctly understands that the most essential step in this process is
1. Wiping the rubber stopper of the vial with alcohol before and after needle insertion. 2. Instilling the accurate amount of diluent into the vial. 3. Using a filtered needle to draw up the medication. 4. Instilling air into the vial before withdrawing medication.