What is an abnormal finding in a newborn infant?
a. Bluish hands and feet
b. Two veins and one artery in the umbilical cord
c. Apgar score of 9 at 5 minutes after delivery
d. Passage of a meconium stool
ANS: B
The umbilical cord should have one vein and two arteries. The other findings are normal.
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A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
A) Insertion of a nasogastric tube B) Insertion of a central venous catheter C) Administration of a mineral oil enema D) Administration of a glycerin suppository and an oral laxative
The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is:
a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours.
The American Nurses Association established criteria for recognizing standardized terminologies. The terminologies must meet established criteria to be approved
Which of the following are instrumental in the approval process? Select all that apply. 1. Outcome identification 2. Diagnosis 3. Problem solving 4. Decision making 5. Nursing process data elements
If a positive Homans' sign is detected during assessment, the nurse should not perform this assessment again until a clot has been ruled out for which reason?
a. It may cause an embolus. b. It may cause a thrombus. c. It would cause the client emotional distress. d. It would cause the client severe pain.