The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action?
A. insert a rectal tube for the passage of flatus
B. document the finding as the only action
C. assessment of the client's vital signs
D. determine the time the client last voided
Ans: D. determine the time the client last voided
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When planning to answer a 16-year-old girl's questions about menstruation, the nurse must consider cognitive development. What is developed during adolescence according to Piaget?
a. The ability to view a situation from multiple perspectives b. The ability to focus more on the past than present situations c. The ability to exercise concrete reasoning d. The ability to consider hypothetical situations
A camp nurse has been rushed to a playing field where a girl appears to be experiencing an anaphylactic reaction. The nurse has had the child rushed to the camp's infirmary
What action should the nurse prioritize in the immediate care of this child? A) Administer analgesics if available. B) Closely monitor the girl's heart rate. C) Position the girl in high Fowler's. D) Maintain the patency of the girl's airway.
An older patient has been hospitalized twice in one year for a lung infection. How should the nurse describe the relationship between aging and risk of infection?
1. "With aging, the immune system diminishes and then stops working." 2. "With aging, there is an overall increase in the speed of the immune response." 3. "With aging, there is an increase in the number of B cells, which hinders the immune response." 4. "With aging, there is a decrease in the strength of the immune system, increasing the risk for infection."
Pressure ulcers are a potential complication of anti-embolism hosiery.
Answer the following statement true (T) or false (F)