During the assessment of a 2-month-old infant's reflexes, the nurse placed a finger in the baby's hand and pressed against the palm. The baby flexed all fingers to grasp the nurse's finger. How would the nurse document this finding?
A) Plantar grasp reflex intact
B) Moro reflex intact
C) Support reflex intact
D) Palmar grasp reflex intact
D
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A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take?
a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for an emergency airway.
__________ is a continually changing state of well-being that encompasses an individual's physical, social, and mental well-being
Fill in the blank(s) with correct word
The ambulatory care nurse would arrange for periodic monitoring of blood levels for a client with COPD who is beginning to use
a. beclomethasone (Vanceril). b. ipratropium (Atrovent). c. theophylline (Theo-Dur). d. zafirlukast (Accolate).
What intervention should the nurse teach the client with diabetes who uses an insulin infusion pump to prevent the complication of infection?
A. "Test your urine daily for the presence of ketone bodies." B. "Use buffered insulin to prevent crystal formation." C. "Keep the insulin frozen until you fill the pump." D. "Change the needle every 3 days."