The nurse, providing a cleansing enema to an adult client, should do which of the following?
a. Ensure the temperature of the water is 115°F.
b. Hold the enema container 24 inches above the anal opening.
c. Insert the catheter 8 to 10 inches beyond the anal opening.
d. Stop the flow of the enema if the client complains of cramping until the feeling passes.
ANS: D
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The nurse is assessing a patient with possible Cushing's syndrome. In a patient with Cushing's syndrome, the nurse would expect to find:
A) Hypotension B) Thick, coarse skin C) Deposits of adipose tissue in the trunk and dorsocervical area D) Weight gain in arms and legs
What disorder of the thorax or lung best describes her symptoms?
A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement, and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia
Choose the action the nurse should take to elicit the oculocephalic response in a motor vehicle accident victim who is unconscious
a. Use a wisp of cotton to stimulate the cor-nea. b. Hold the eyelids open while turning the client's head. c. Squirt ice water into the client's ear canal. d. Hold both eyelids open and shine a bright light into the eyes.
Which ethical theory is most applicable to the practice of a nurse, which focuses on following
hospital policy rather than benefiting the community as a whole? A) Situational ethics B) Virtue ethics C) Deontology D) Utilitarianism