The nurse is caring for a patient who has a nephrostomy tube. What action should the nurse take?
a. Limit fluids to 1,000 mL per 24 hours.
b. Keep collection bag taped to abdomen.
c. Ensure tube is not kinked or clamped.
d. Remove and clean the tube once daily.
ANS: C
For a nephrostomy tube, ensure that it is draining adequately and prevent kinking or clamping of the tube.
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A nurse performing an admission assessment on a patient with suspected tuberculosis knows that the risk of exposure to tuberculosis is greatest:
a. after a diagnosis is made. b. before a diagnosis is made. c. after the patient has begun medication therapy. d. after implementation of isolation precautions.
The nurse is discussing goals to relieve pain and fatigue with a client newly diagnosed with fibromyalgia. Which goal statement would be realistic for this client to achieve within 30 days?
A) Cook dinner five nights a week. B) Join an exercise group. C) Walk her son to school daily. D) Get a job outside the home.
When caring for a client with new-onset diabetes, which of the following diagnostic tests supports this diagnosis?
1. Hemoglobin A1C of 8.4 2. Fasting glucose level of 74 mg/dL 3. Proteinuria 4. Hypokalemia
Assessment tools can be very helpful for nurses working with families in a variety of situations. One tool that can assist the nurse in understanding the family structure and the strength of relationships is the
1. Behavioral health indicator. 2. Ecomap. 3. Family health assessment. 4. Family health tree. 5. Genogram.