A nurse on a postsurgical unit is providing care for 20-year-old man who had an open appendectomy performed earlier this morning. Which of the following assessment findings should prompt the nurse to contact the patient's surgeon?
A) The patient has put out 35 mL of urine in the 7 hours since admission.
B) The patient is complaining of nausea and has received a dose of metoclopramide (Reglan).
C) The patient's peripheral IV has gone interstitial.
D) The patient has stated that he has no place to go after he is discharged and lacks a social support system.
A
You might also like to view...
A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:
a. contraction pattern, amount of discomfort, and pregnancy history. b. fetal heart rate, maternal vital signs, and the woman's nearness to birth. c. last food intake, when labor began, and cultural practices the couple desires. d. identification of ruptured membranes, the woman's gravida and para, and her support person.
The community health nurse visits the child-care center. Which finding indicates the need for staff education?
1. A group of 2 -year-olds are eating asnack of Cheerios. 2. Several 4-year-olds are outsideplaying on a slide. 3. An 18-month-old is pushing a toytruck. 4. A 2-month-old is sleeping in a crib onhis stomach.
A client has the goal statement "Client will have clear lung sounds bilaterally within 3 days." One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours
At the end of the third day, the client's lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention. 4. Write this evaluation statement: Goal met, lung sounds clear by third day.
The branch of the government involved in interpreting the states' rights to grant abortions is the:
1. Executive branch 2. Legislative branch 3. Judicial branch