The nurse is caring for four patients. Which patient's assessment information supports the nurse's decision to remove the nasogastric (NG) tube after the order by the healthcare provider is completed?
a. Restless, confused, without bowel sounds
b. Difficulty swallowing from left-sided stroke
c. Not passing gas with lack of appetite
d. Abdomen slightly rounded with incisional pain
D
The patient with a slightly rounded abdomen and incisional pain should have the NG tube re-moved because a rounded abdomen does not carry the risks of distention and incisional pain is a factor that does not interfere with NG tube removal. The nurse manages the patient's pain with analgesic, keeping in mind that opioids usually lead to constipation. The restless patient and the patient with dysphagia are at high risk for aspiration because the patient potentially cannot pro-tect the airway and needs the NG tube to help prevent aspiration of gastric contents. The patient who is not passing gas and is experiencing anorexia is not a suitable candidate for NG tube re-moval because lack of intestinal gas indicates peristaltic impairment. The anorexia is a logical sequela of impaired peristalsis because patients lose their appetites with gastric paresis.
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After administering a medication to a client, the nurse realizes that the client was given another client's drug. What must the nurse do next?
a. Administer the original drug, and observe the client frequently for adverse reactions to the first drug. b. Call the health care provider immediately, and complete an incident report. c. Check the client's MAR for drug allergies, and if there is no indicated allergy to the drug administered in error, no further action is necessary. d. Document the error on the client's medical record, and notify the supervisor.
The nurse is caring for a patient with bipolar disorder who has been awake for 72 hours and has eaten only small amounts of food. The patient's speech is pressured and unorganized. When planning care for this patient,
what priority nursing diagnosis will the nurse formulate? 1. Alteration of sleeping pattern due to acute mania, as evidenced by decreased sleep. 2. Alteration of sleeping pattern caused by acute mania, manifested by decreased sleep. 3. Risk for injury caused by acute mania, manifested by altered nutrition, decreased sleep, and pressured speech. 4. Risk for injury due to acute mania, as evidenced by altered nutrition, decreased sleep, and pressured speech.
The nurse is aware that physical growth retardation is a common finding in aneuploid conditions. Which assessment findings are generally associated with this growth pattern?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Microcephaly 2. Facial malformations 3. Small heart size 4. Compressed rib cage 5. Lack of body hair
A patient has a higher risk of peptic ulcer disease (PUD) if they are a chronic user of
a. certain antibiotics. b. laxatives and stool softeners. c. magnesium-aluminum antacids. d. nonsteroidal antiinflammatory drugs.