The results of a total serum bilirubin test done on an infant at 52 hours old is 14 milligrams per deciliter. What is the most appropriate initial nursing action?
a. Contact the physician promptly for further orders.
b. Prepare for immediate exchange transfusion.
c. Discontinue breastfeeding, and start soy-based formula.
d. Repeat the test for clarification.
A
The most appropriate initial nursing action is to contact the physician for further orders. The peak for physiologic jaundice is 7 mg/dL. When reporting the bilirubin blood level to the physician, it is important to include the age of the infant in hours so that appropriate management can be determined. It should be noted that when bilirubin levels are elevated, the infant's fluid intake should be increased.
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The nurse is working with a family in the process of a divorce. The parents are pressuring the children to decide which parent to live with after the divorce
The children are conflicted because they love both parents equally and want the family to stay together. This is an example of a: 1. Schismatic family. 2. Skewed family. 3. Hostile family. 4. Disengaged family.
What clinical finding would the nurse expect to observe in the client who has just undergone a peritoneovenous shunt placement?
A. Decreased level of consciousness B. Decreased urinary volume C. Increased blood pressure D. Increased abdominal girth
If the nurse is the subject of a lawsuit, the nurse will typically attempt to demonstrate that his/her behavior was appropriate. To do this most effectively, the nurse may use which of the following?
A. Call an expert witness to testify that the behavior was prudent and reasonable for a nurse in such a situation. B. An attorney will argue that the physician was responsible for the nurse's behavior, and therefore the suit should be against the physician. C. Confirm that the textbooks the nurse had while enrolled in nursing education suggested the action that the nurse performed. D. Explain that the client told the nurse to engage in that behavior, and the client has the authority to decide on personal care.
The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. The nurse should employ which techniques to best protect the back? (Select all that apply.)
1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible. 5. Bend over and use a jerking motion to pull the box to waist level.