The nurse develops what priority goal for the infant with cleft lip and palate prior to surgery?
1. Crying will be limited to no more than one minute.
2. Will maintain adequate nutrition without aspirating.
3. Will maintain hemoglobin within normal limits.
4. Will maintain normal oxygen saturation.
2
Rationale: The goal in caring for this infant will be to supply adequate nutrition while preventing aspiration.
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Mr. Tyler, a 68-year-old black man, complains of urinary frequency and an interrupted stream. What would be an appropriate response?
a. Discuss with him that he may have prostate cancer b. Suggest that he see a physician for a PSA test c. Tell him it is a completely normal part of aging d. Tell him to accept it and do nothing
When a staff member makes a mistake, the nurse manager should:
1. ignore the mistake and give the person another chance. 2. punish the person. 3. call all staff members together to discuss the mistake. 4. accept the mistake and help the person learn from the mistake.
Which of the following are direct measures? (Select all that apply.)
a. The patient's radial pulse rate b. The dimensions in centimeters of a decubitus ulcer c. The nurse's observations of an infant's apparent pain d. The physician's measure of the patient's deep tendon reflexes e. The patient's estimate as to whether his lithium level is within therapeutic range f. The mother's report of her toddler's anxiety level before a blood draw g. The patient's serum serotonin levels
A client has been diagnosed as having impaired swallowing and complains of frequent heartburn. The nurse should:
1. Assist the client in maintaining a sitting position for 30 minutes after the meal. 2. Teach the client the "chin tuck" technique when swallowing. 3. Check the client's mouth for pocketing of food. 4. Assist the client to a 90°sitting position, or as high as tolerated, during meals.