The nurse suspects a patient recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. What findings did the nurse use to make this clinical decision?
Select all that apply.
1. urine output 45 mL/hr
2. complaint of groin pain
3. abdominal dressing dry and intact
4. respiratory rate 16 and regular
5. complaint of back discomfort
Correct Answer: 2, 5
The nurse should monitor for and report any back, or groin pain. The urine output needs to be below 30 mL/hr before reporting. A dry abdominal dressing and respiratory rate of 16 and regular are expected findings.
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A client wants to use the vaginal sponge as a method of contraception. Which statements indicate that the client needs further instruction?
Select all that apply. A) "I need to leave it in no longer than 6 hours." B) "I need to use a lubricant prior to insertion." C) "I can insert the sponge no longer than 24 hours prior to having intercourse." D) "I need to add spermicidal cream prior to intercourse." E) "I need to moisten it with water prior to use."
The nurse is providing patient teaching about antacids. Which statements about antacids are accurate?
(Select all that apply.) a. Antacids reduce the production of acid in the stomach. b. Antacids neutralize acid in the stomach. c. Rebound hyperacidity may occur with calcium-based antacids. d. Aluminum-based antacids cause diarrhea. e. Magnesium-based antacids cause diarrhea.
The nurse should describe pain that is causing the client a "burning sensation in the epigastric re-gion" as:
1. Referred 2. Radiating 3. Deep or visceral 4. Superficial or cutaneous
A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child's pulse oximetry status?
a. Continuous b. Every 30 minutes c. Every hour d. Every 2 hours