The nurse wants to promptly detect paralytic ileus in the client after a total abdominal hysterectomy. Which does the nurse use to assess for paralytic ileus?
1. Auscultate bowel sounds every 4 hours.
2. Palpate suprapubic region for distention.
3. Evaluate the client's postoperative appetite.
4. Administer stool softeners for prophylaxis.
1
1 and 2. Most clients resume bowel function within days of an abdominal procedure, but it potentially takes longer when the client takes opioid analgesics for pain control. The nurse auscultates bowel sounds every 4 hours, asks the client whether gas is passing, and palpates the abdomen for distention for early detection of paralytic ileus to prevent a bowel obstruction and client pain.
3. The client's appetite can be unaffected by a paralytic ileus at first; the nurse avoids assessing appetite to detect a paralytic ileus. If the ileus continues, clients usually lose their appetite and begins vomiting after eating.
4. Administering stool softeners is a nursing action but not an assessment technique.
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HIPAA and the American Recovery and Reinvestment Act of 2009 specify that personal health records must be protected. Nurses can protect client privacy by:
1. Whispering when discussing clients in the elevator. 2. Placing flow sheets on the client's bed. 3. Not posting clients' names where they can be viewed by visitors. 4. Sharing passwords with floating nurses.
The nurse explains that the ______________ test determines the child's susceptibility to tuberculosis
ANS:
A homeless man, age 66, is admitted to the acute care facility. He was found lying in an alley. An investigation revealed the individual is homeless and does not have any available family members. The client is unresponsive at the time of admission
The prognosis is guarded. Which action by the healthcare facility is indicated? A) Notify a local homeless shelter. B) The hospital will approach a judge to have the client become a ward of the state. C) The hospital will assume implied consent for care for a period of 48 hours and then move forward if there is no change to name a guardian. D) The client will be represented by the hospital social worker until he regains consciousness or a guardian is appointed.
The nurse is caring for a client with exposure to an unknown chemical agent. The client asks, "Why can't a lab test be done to determine which agent I was exposed to?" What is the nurse's best response?
A) "There is no way to determine exactly which test to run." B) "Obtaining results from a lab test would take longer than treatment would." C) "There are no lab tests available to identify the chemical." D) "It is more important to understand the type of injury you have."