In caring for a client who has a fever, it would be important for the nurse to monitor for increased:
1) Urine output
2) Sensitivity to pain
3) Blood pressure
4) Respiratory rate
ANS: 4
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The nurse is teaching the mother of a 5-year-old boy with a history of impaction how to administer enemas at home. Which of the following responses from the mother indicates a need for further teaching?
A) "I should position him on his abdomen with knees bent.". B) "He will require 250 to 500 mL of enema solution.". C) "I should wash my hands and then wear gloves.". D) "He should retain the solution for 5 to 10 minutes.".
The nurse is performing a surgical hand scrub prior to entering the operating room. The circulating nurse will stop the nurse and reinstruct on proper hand scrubbing if the nurse does which action?
A. After wetting the hands and forearms, the nurse holds the hands above the level of the elbows. B. The nurse spends 25 to 30 seconds rubbing soap on the tops and palms of hands using an up-and-down motion. C. The nurse keeps the arms elevated and backs into the operating room. D. The nurse uses a sterile towel to dry one hand from fingers to the elbow and then picks up a second sterile towel for the other hand.
The nurse leading parent education classes bases instruction on Erikson's developmental stages. It follows that the nurse will plan to instruct the parents that a helpful strategy to foster a child's initiative would be to:
1. Offer options for dressing 2. Allow the child to help wash unbreakable dishes 3. Place the child in enrichment learning programs at age 2 4. Promote experimentation in playthings
What is the purpose of making general observations during the assessment process for an infant during a scheduled health maintenance visit? Select all that apply
1. To invite discussion with the parents 2. To validate positive parenting efforts 3. To promote a partnership between healthcare providers and parents 4. To decrease the risk of communicable diseases 5. To meet standards required for The Joint Commission accreditation