Which of the following are examples of evidence standards that may be used in court?
a. Expert testimony
b. Agency regulations
c. Facility or agency documents
d. Professional nursing guidelines
e. All of the above
E
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Which assessment finding alerts the nurse to the likelihood that the patient has a distended bladder?
1. Percussion in the middle of the lower abdomen elicits a dull sound. 2. The patient states, "My back is killing me.". 3. Percussion over the costovertebral angle produces pain. 4. The patient complains of colicky pain in the side.
An unconscious patient requires mouth care every 2 hours. Before attempting mouth care, the nurse should first:
A. assess the patient for a gag reflex. B. position the patient in a prone position. C. have an operational suction machine nearby. D. retract the upper and lower teeth with a padded tongue blade.
A patient is to receive desmopressin for diabetes insipidus. By which routes may the drug be administered? You may select more than one answer
a. By mouth b. IV c. By nasal spray d. Subcutaneously e. IM
A patient admitted with acute pancreatitis has a nasogastric tube, is in pain, and is on bed rest. The patient says, "I don't understand why I can't eat." How should the nurse respond?
1. Start the patient on a small amount of clear liquids. 2. Explain the purpose of the nasogastric tube and the reasons for keeping the patient NPO. 3. Tell the patient that pain medication is limited to prevent addiction. 4. Tell the patient that IV fluids are sufficient for now.