A client receiving gastrostomy feedings develops diarrhea. The nurse should:
A. Aspirate stomach contents
B. Discontinue the feedings
C. Maintain the client in a side-lying position
D. Review the client's medications and type of formula
D
D. Determine if client is receiving antibiotics or medications (e.g., those containing sorbitol), which can induce diarrhea. Notify physician and confer with dietitian to determine need to modify type of formula, concentration, or rate of infusion.
A. Stomach contents are aspirated to determine tube placement.
B. Excessive gastric residual volume—Notify physician to determine if feedings need to be held. If feedings are held, reassess residual volume 1 hour after the feeding is stopped to determine if volume has lessened or increased.
C. Position the client on side to protect the airway.
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A patient with a large thermal burn injury is found to have depressed cardiac contractility and a resultant low cardiac index. What is the underlying, primary, physiologic rationale for this situation?
A) Inflammation-triggered release of nitric oxide B) Reduction of platelet aggregation and adhesion C) Decreased intravascular volume from third spacing D) Peripheral vasodilatation from inflammation
Following an arthrocentesis of the right knee in the physician's office, the nurse gives the following instructions to the client:
A) Apply warm moist heat as needed for pain relief. B) Remove the pressure dressing when you get home. C) Limit use of the joint for 2 to 3 days. D) Begin range-of-motion exercises to the knee in 24 hours.
A nurse complains to the supervisor that horizontal violence (bullying) is occurring on the unit. The nurse most likely indicates to the supervisor that which of the following was occurring on the unit? Select all that apply
a. Intimidation d. Faultfinding b. Verbal abuse e. Support c. Camaraderie f. Elitist attitude
What must a person do to avoid the effects of extreme temperatures?
(A) Eat food. (B) Find shelter. (C) Drink water. (D) Get plenty of sleep.