A nurse is assessing a 9-month-old infant. Which reflexes would the nurse expect to assess? Select all that apply
A) Rooting
B) Sucking
C) Tonic neck
D) Moro
E) Palmar grasp
F) Babinski
B, F
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The patient has been diagnosed with severely compromised immune function. What nursing intervention is most important?
A) Antibiotic therapy B) Adequate protein C) Coughing and deep breathing D) Restricted visits from family
The patient's sacrum has nonblanching redness on Monday. On Wednesday the nurse determines that the pressure ulcer on the patient's sacrum is stage II despite skin care, including an air-filled mattress overlay
Which is the best nursing intervention to implement? a. Document the extreme progression of the patient's pressure ulcer. b. Collaborate with the healthcare provider for physical therapy. c. Reassess the patient's need for a different support surface or bed. d. Increase the frequency of bathing and li-nen changes as needed.
A nurse is caring for a patient with cancer who has been undergoing chemotherapy. The patient has oral mucositis as a result of the chemotherapy, and the provider has ordered palifermin (Kepivance)
Which is an appropriate nursing action when giving this drug? a. Administering the drug as a slow IV infusion b. Flushing the IV line with heparin before infusing the drug c. Giving the drug within 6 hours of the chemotherapy d. Warning the patient about the potential for distortion of taste
If a patient has had hip surgery, never elevate the head of the bed more than
A. 90 degrees without specific permission. B. 75 degrees without specific permission. C. 45 degrees without specific permission. D. 30 degrees without specific permission.