The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention?
A. Gastric pH of 4.0 during placement check
B. Weight gain of 1 pound over the course of a week
C. Active bowel sounds in the four abdominal quadrants
D. Gastric residual aspirate of 350 mL for the second consecutive time
Ans: D. Gastric residual aspirate of 350 mL for the second consecutive time
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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
The pediatric nurse is aware of the maturation of organ systems in the school-age child. Which of the following accurately describe these changes? Select all answers that apply
A) The brain grows very slowly during the school-age years and growth is complete by the time the child is 12 years of age. B) Respiratory rates decrease, abdominal breathing disappears, and respirations become diaphragmatic in nature. C) The school-age child's blood pressure increases and the pulse rate decreases, and the heart grows more slowly during the middle years. D) The school-age child experiences more gastrointestinal upsets compared with earlier years since the stomach capacity increases. E) Bladder capacity increases, but varies among individual children, and girls generally have a greater bladder capacity than boys. F) Prepubescence typically occurs in the 2 years before the beginning of puberty and is characterized by the development of secondary sexual characteristics.
The nurse is caring for a patient who will be evaluated for brain death. What should the nurse expect to be evaluated in this patient?
Select all that apply. 1. absent motor and reflex movements 2. flat electroencephalogram (EEG) on successive EEGs 3. no spontaneous respiration 4. pupils are equal and responsive to light 5. criteria present for at least 15 minutes
A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse's first action?
a. Assess level of consciousness and lung sounds b. Check the tightness of the straps and mask c. Notify the health care provider immediately d. Remove the mask and administer supplemental oxygen