The nurse is admitting an elderly patient for failure to thrive and weight loss. A nasogastric tube is inserted for supplemental tube feedings. The nurse should become concerned when (Select all that apply.)
a. Bleeding is noted where the tube comes in contact with the nares.
b. Nasal mucosa is pink.
c. No discharge from the nose is noted.
d. Clear, watery discharge is noted.
ANS: A, D
If patients have any form of tubing exiting the nose (e.g., nasogastric), observe for tissue damage, localized tenderness, inflammation, drainage, and bleeding where the tubing comes in contact with the nares. Allergies cause a clear, watery discharge. The nasal mucosa is normally pink and clear and has little or no discharge.
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The nurse is preparing to teach a client who works as a college professor at the local university, and plans to use a cognitive approach. Which of the following strategies displays this approach?
1. Give the client relevant information. 2. Help the client to set appropriate goals. 3. Provide an atmosphere conducive to learning. 4. Begin by assessing the client's developmental level.
The patient is eager to begin his exercise program with a 2-mile jog. The nurse instructs the patient to warm up with stretching exercises. The patient states that he is ready and does not want to waste time with a "warm-up."
The nurse explains that the warm-up a. Allows the body to readjust gradually to baseline functioning. b. Prepares the body and decreases the potential for injury. c. Should not involve stretching exercises because they can lead to injury. d. Should be performed with high intensity to prepare for the coming challenge.
Which assessment findings indicate to the nurse a child has Down syndrome? (Select all that apply.)
a. High arched narrow palate b. Protruding tongue c. Long, slender fingers d. Transverse palmar crease e. Hypertonic muscle tone
Handwashing should be performed for a minimum of
A. 5 to 10 seconds. B. 10 to 15 seconds. C. 15 to 20 seconds. D. 20 to 30 seconds.