The nurse is unable to aspirate any residual volume from the patient who receives intestinal tube feedings at a rate of 200 mL every 6 hours by intermittent gavage. Which action should the nurse implement?
a. Insert a nasogastric tube.
b. Withhold the next feeding.
c. Notify the patient's healthcare provider.
d. Administer the next feeding.
D
The nurse expects to aspirate no residual volume from the patient who receives intermittent in-testinal tube feedings because the small intestines are unable to sequester fluid. The placement of this type of tube is verified by x-ray film; and, if nothing is aspirated afterward, it is assumed that placement of the tube is correct.
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The nurse observes the unit clerk providing the hospital chaplain with clients' religious affiliations. The nurse's priority action is to:
1. Do nothing. 2. Stop the unit clerk and reprimand her privately for sharing privileged information. 3. Inform the chaplain that signed permission will be required to provide that information. 4. Do nothing, but speak to the unit clerk later about HIPAA privacy laws.
When the client arrives in the intensive care unit following CABG surgery, the nurse obtains the reports from laboratory work including chemistries, a complete blood count (CBC), arterial blood gases (ABGs), and a chest x-ray; an ECG should be done
as soon as possible. The rationale for obtaining this data is: 1. To establish a baseline for future assessments. 2. To provide the client's family with the information. 3. To provide fellow nurses with the information. 4. To report to the surgery nurses.
The client receives cyclophosphamide (Cytoxan) as treatment for cancer, and is experiencing oral irritation as an adverse effect. What does the best plan by the nurse include as it relates to providing oral comfort?
1. Teach the client to avoid extreme temperatures of food selections. 2. Teach good oral hygiene, including the use of an antiseptic mouthwash. 3. Administer megestrol (Megace ES) to the client. 4. Teach the client to use a firm toothbrush for brushing the teeth.
Which of the following strategies would a nurse expect to be implemented by a typical state environmental agency? (Select all that apply.)
a. Acting, through unannounced inspections, to ensure compliance b. Writing permits that help limit toxic hazards c. Monitoring hazardous substances to uphold established standards d. Obtaining and analyzing samples to confirm compliance