A young male patient has been brought to the emergency department with a knife wound to the abdomen. When the patient's hands are removed from the area of the wound to facilitate assessment, the patient's intestine protrudes from the wound
How should the nurse respond to this development?
A) Cover the protruding viscera with saline-soaked, sterile gauze.
B) Don sterile gloves and attempt to push the organ back inside the wound.
C) Irrigate the protruding intestine with sterile water or normal saline.
D) Apply a pressure dressing to the wound.
A
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The nurse knows an appropriate outcome statement for the nursing diagnosis Impaired swallowing is:
a. the patient will consume 50% of his meal. b. the patient will gain 2 lb a week. c. the patient will show any signs of aspiration during meals. d. the patient will demonstrate using an assistive device to feed himself.
The nurse is caring for a patient with a heightened stress response following a fearful experience. When assessing this patient, what findings will the nurse attribute to this response? (Select all that apply.)
A) Elevated serum blood glucose B) Reduced inflammatory response C) Heightened immune response D) Increased blood volume E) Extreme hunger
The most important nursing intervention to assure the patency of a nasogastric tube (NG) is to:
a. Clamp nasogastric tube 30 minutes twice a day. b. Monitor NG for patency and irrigate with sterile normal saline PRN as ordered. c. Cleanse nares at least once each shift; lubricate with a petrolatum ointment. d. Administer mouth care every 24 hours.
In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:
a. The father of the infant. b. Her mother (the infant's grandmother). c. Her eldest daughter (the infant's sister). d. The nurse.