A patient reports having abdominal distention. The nurse notices that the patient's sclerae are yellow. What question is appropriate for the nurse to ask in response to this information?
a. "Has there been a change in your usual pattern of urination?"
b. "Have you had any nausea or vomiting?"
c. "Has there been a change in your bowel habits?"
d. "Have you had indigestion or heartburn?"
ANS: B
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The nurse is acting as medication nurse for the unit. How often will the nurse document medication administration?
1. Every 2 hours for all clients 2. Every 4 hours for all clients 3. At the end of the shift for all clients 4. After each client receives a medication
You are caring for a client with multiple myeloma. Why would it be important to assess this client for fractures?
A) Osteopathic tumors destroy bone causing fractures. B) Osteoclasts break down bone cells so pathologic fractures occur. C) Osteolytic activating factor weakens bones producing fractures. D) Osteosarcomas form producing pathologic fractures.
The nurse, planning care for a client recovering from a traumatic brain injury, is including interventions to prevent sympathetic storming. Which of the following should be included in this client's plan of care? (Select all that apply.)
1. Medicate for pain prior to conducting a painful procedure. 2. Elevated blood pressure indicates a sympathetic storm is ending. 3. Continue suctioning until the client's heart rate is greater than 100 beats per minute. 4. Cardiac arrhythmias indicate a drop in intracranial pressure. 5. Provide beta-blockers as prescribed with symptoms of sympathetic storm. 6. If symptoms of sympathetic storm do not appear within 24 hours, the client will not develop this health problem.
The newborn tries to maintain an adequate body temperature by producing as much heat as is lost. If a baby is wet or left in damp clothes or blankets, the nurse recognizes that the infant will most likely lose heat by which mechanism?
A) Conduction B) Convection C) Radiation D) Evaporation