A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first?
a. Administer bulk-forming laxatives.
b. Assist the patient to sit on the toilet.
c. Manually remove the impacted stool.
d. Increase the patient's oral fluid intake.
c. Manually remove the impacted stool.
The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.
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Peripheral cyanosis is abnormal in newborns
A) True B) False
During a well-baby check the nurse notices the infant does not demonstrate the expected developmental milestones for this age. Which of the following nursing interventions should be completed first?
1. The nurse should initiate a consult with social services for a home assessment. 2. The nurse should consult with the health care provider. 3. The nurse should ask the parents questions about their play activities with the infant. 4. The nurse should prepare the family for a potentially upsetting diagnosis.
A client is being treated for bleeding esophageal varices with a Sengstaken-Blakemore tube. Nursing care will include which of these approaches?
a. allowing the client to assume a position of choice b. emptying the drainage bottle and recording output c. periodically deflating the balloon d. providing sips of ice water every 30 to 45 minutes
A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. c. Disturbed body image: Encourage patient to express concerns about body. d. Caregiver role strain: Identify resources to assist with care.