A patient with esophageal variceal bleeding unresponsive to endoscopic therapy is receiving a balloon tamponade tube. Which of the following is an appropriate nursing intervention related to this procedure?
A) Warm the tube before the physician inserts it.
B) Lower the head of the bed so that the patient's feet are above his heart.
C) Encourage the patient to cough.
D) Clean and lubricate the patient's nostrils.
D
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While the nurse is performing a nutritional assessment her patient states, "I am on a vegan diet. I have been a vegan for 10 years. What do think?" What is the best response by the nurse?
a. "Is this a religious or cultural requirement for you?" b. "It is fine; however, you may not be getting all the nutrients you need." c. "Can you tell me about the foods you eat along with any other supplements you take?" d. "I think it is your right to be on whatever diet you would like to be on."
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia
The reasonable person standard states that:
a. it takes a reasonable person to maintain a good relationship b. reasonable people tend to have reasonable children and make good partners c. it is used to demonstrate a breach of duty d. it is used by State Boards of Nursing to evaluate the male-female ratios according to clinical position
A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension?
A) Administer an IV bolus of normal saline prior to repositioning. B) Maintain bed rest until normal BP regulation returns. C) Monitor the patient's BP before and during position changes. D) Allow the patient to initiate repositioning.