Which physical assessment technique will the nurse omit when caring for a 2-year-old diagnosed with Wilms' tumor?
a. Performing range-of-motion exercises on lower extremities
b. Palpating the abdomen
c. Assessing for bowel sounds
d. Percussing ankle and knee reflexes
ANS: B
Palpation of the abdomen could disturb the tumor and cause the malignancy to spread.
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The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention?
1. "I will put my baby to bed with his bottle so he doesn't get hungry during the night." 2. "My baby will probably have a bowel movement each breastfeeding, and will wet often." 3. "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." 4. "I will drink fenugreek tea from my grandmother to prevent my milk from coming in."
You recognize that an FHR tracing has been showing a decrease in variability for the last 45 minutes. Your first intervention should be to
A. Encourage ambulation B. Administer oxygen C. Discontinue IV fluids D. Increase Pitocin rate
A patient is admitted to the hospital with a suspected case of botulism. The nurse recognizes that which situation likely caused this infection?
A. The patient ate food contaminated with the toxin. B. The patient was injected with the poison. C. The patient came in contact with someone who had botulism. D. The patient had a dirty wound that became infected with the toxin.
A patient has been treated for mild phlebitis. Which discharge teaching should the nurse provide?
1. "You should stop smoking." 2. "Do not travel by air." 3. "Increase your fluid intake." 4. "When you travel, stop frequently and walk around." 5. "Adopt a low-fat diet."