The nurse is caring for a 4-year-old boy with infectious conjunctivitis. Which intervention would be least appropriate to include in the child's plan of care?
A) Rinsing the eye with cool water
B) Educating the family about the disease
C) Encouraging frequent hand washing
D) Promoting eye safety
D
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During auscultation of all four quadrants of a client's abdomen, the nurse hears 20 or more bowel sounds per minute. How should this finding be documented?
a. "bowel sounds absent" c. "bowel sounds hyperactive" b. "bowel sounds active" d. "bowel sounds hypoactive"
A client with acute urinary retention is prescribed catheterization. Which of the following measures should be taken by the nurse to ensure accurate residual volumes?
A) Use always a coudé catheter. B) Record the volume of urine if it is more than 700 mL. C) Record the volume of urine if it is less than 30 mL. D) Record both the volume voided and the volume obtained by catheterization.
The mechanism responsible for the rejection of transplanted tissue and the destruction of single malignant cells is known as immunosurveillance. The nurse understands that this is a function of:
a. helper T lymphocytes. b. suppressor T lymphocytes. c. T4 lymphocytes. d. killer T lymphocytes.
The nurse assessing acutely ill clients who are at risk for multiple organ dysfunction syndrome (MODS) would assess for the usual precipitating manifestation of
a. bradycardia. b. cerebral anoxia. c. high creatinine level. d. hypotension.