The nurse prepares a dietary plan for a patient who practices Orthodox Judaism and notes that no Jewish holidays are approaching. What choices does the nurse plan to exclude from the patient's menu?
a. Caffeinated tea
b. Grilled cheese sandwich
c. Milk products
d. Lobster chowder
D
The patient practicing Orthodox Judaism cannot eat shellfish; so the nurse eliminates lobster from the patient's dietary plan. Orthodox Jewish dietary guidelines do not restrict dietary intake of dairy products except that dairy products are not eaten at the same meal with meat. The patient's religious practices allow caffeine in the diet. All followers of Judaism avoid eating leavened bread such as regular bread during Passover but may have it the rest of the time unless fasting.
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Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
A) Complete the pin site care to decrease risk of infection B) Notify the neurosurgeon of the occurrence C) Stabilize the head in a lateral position D) Reattach the pin to prevent further head trauma
Which are assessment findings that support a diagnosis of sexual abuse for a pediatric patient? Select all that apply
1) Bruises 2) Anal penetration 3) Fractures 4) Genital fondling 5) Intentional burns
The nurse is completing an assessment of an older client's oral cavity. Which finding most concerns the nurse?
1. Leukoplakia 2. Gum redness 3. Excess saliva 4. Multiple cavities
A client is being transferred to the postanesthesia care unit (PACU) after surgery. The client has an endotracheal tube (ET) in place
On assessment, the client has oxygen saturation of 95%, res-piratory rate of 14 breaths/min, and asymmetric chest wall expansion. What is the nurse's best action? a. Attempt to awaken the client. b. "Bag" the client with a resuscitation bag. c. Increase the client's fraction of inspired oxygen (FIO2). d. Auscultate lung sounds bilaterally.