The nurse is caring for a patient with pancreatic cancer
The nurse closely monitors for jaundice, knowing that which assessments closely correlate with jaundice? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Pruritus
2. Pain
3. Vision disturbances
4. Nausea
5. Skin lesions
1,5
Rationale 1: Pruritus usually accompanies jaundice. Therefore, the patient may also require care for itching to avoid damaging the skin.
Rationale 2: Pain does not accompany jaundice.
Rationale 3: Vision disturbances do not accompany jaundice.
Rationale 4: Nausea may accompany pancreatic cancer but is not necessarily associated with jaundice.
Rationale 5: Skin lesions may result from scratching.
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The nurse is administering an IV push medication through an IV lock. After injecting the medication, which action will be taken next?
a. Flushing the lock b. Regulating the IV flow c. Clamping the tubing for 10 minutes d. Holding the patient's arm up to improve blood flow
The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which knowledge?
a. Surgery is recommended as soon as possible. b. The defect usually resolves spontaneously by 3 to 5 years of age. c. Aggressive treatment is necessary to reduce its high mortality. d. Taping the abdomen to flatten the protrusion is sometimes helpful.
Persons receiving tube feedings are at risk for aspiration. You need to report which of the fol-lowing to the nurse at once?
a. Complaints of headache b. Coughing c. Dry mouth d. Pulse rate of 72
The nurse is planning to assess the blood pressure of a patient with a BMI of 40
Which approaches will the nurse use to correctly obtain this patient's blood pressure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use a cuff with a bladder that is 80% of the patient's arm circumference. 2. Use a thigh cuff. 3. Use an adult cuff on the patient's forearm. 4. Assess the blood pressure using the same approach each time. 5. Use an adult cuff on the patient's thigh.