The nurse is assessing the inguinal area on a male patient and notes a bulge. Which conclusions by the nurse are appropriate? Select all that apply
1) The patient may have a hernia.
2) The patient may have a hydrocele.
3) The patient may have an enlarged lymph node.
4) The patient may be impotent.
5) The patient may be infertile.
ANS: 1, 3
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The nurse is planning a teaching session with the client who had major abdominal surgery yesterday. Which of the following is a priority nursing intervention before beginning the teaching session?
1. Assess and treat the client's pain level before beginning teaching. 2. Assess the client's vital signs prior to teaching. 3. Assist the client into a chair at the bedside. 4. Answer the client's questions.
The prescription for the client's IV infusion reads, "100 ml/hr.". The nurse observes the client's IV infused 125 ml in addition to the intended volume after 2 hours. Which is the most important intervention for the nurse to implement?
1. Compare weight to baseline data. 2. Replace the infusion pump batteries. 3. Assess client for respiratory distress. 4. Reduce infusion rate below 75 ml/hr.
The wife of a client currently hospitalized in an extreme manic state is worried about her husband's physical health. She asks the nurse how to tell if the dose of lithium is therapeutic
Which of the following responses by the nurse provides accurate information? A) "Lithium levels will be therapeutic as long as your husband takes the medicine as ordered." B) "Lithium levels will need to be individualized several times a week based on your husband's symptoms." C) "Lithium levels will need to be checked every 2 months once stabilized to make certain." D) "Lithium levels will become therapeutic in about 5 to 6 weeks."
A patient who is to receive bumetanide (Bumex) in 1 hour has less ankle edema and neck vein distention than earlier. What action should the nurse take?
a. Notify the registered nurse. b. Hold the Bumex. c. Give the Bumex early. d. Give the scheduled Bumex.