On the patient's return to the medical-surgical unit, the nurse performs an abdominal assessment. To assess bowel sounds, the nurse auscultates the lower abdomen for
a. 1 minute.
b. 5 to 20 seconds.
c. as long as it takes to hear a bowel sound.
d. one full inspiration and expiration.
A
Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute.
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While observing a female patient on the oncology unit who has a secondary diagnosis of panic attacks, the nurse would expect to observe which of the following symptoms (select all that apply):
A. Nausea. B. Diaphoresis. C. Ritualistic behavior. D. Increased pulse. E. Reliving the experience.
A patient with polymyositisis experiencing challenges with activities of daily living as a result of proximal muscle weakness. What is the most appropriate nursing action?
A) Initiate a program of passive range of motion exercises B) Facilitate referrals to occupational and physical therapy C) Administer skeletal muscle relaxants as ordered D) Encourage a progressive program of weight-bearing exercise
An older adult client had a colon resection 8 days ago. The client experiences a gush of serosanguinous drainage from the wound, feels the abdominal incision "give," and calls the nurse. Viscera are protruding from the wound
Which of these actions must the nurse take FIRST? a. Cover the viscera with sterile saline dressings. b. Notify the surgeon of the situation. c. Place the client on NPO, and begin preparation for emergency surgery. d. Place the client in the semi-Fowler's position.
You are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated at 200 joules, 300 joules, and 360 joules, respectively. The patient remains in VF
According to national standards, you are aware that what medication should be used? A) Epinephrine 1 mg IV push B) Lidocaine 100 mg IV push C) Amiodarone 300 mg IV push D) Sodium bicarbonate 1 amp IV push