The home care nurse is assessing a client who is 10 days postesophagogastrostomy for esophageal cancer. Assessment findings include a temperature of 38° C (101° F), pulse rate of 110, and respirations of 28
What would be the nurse's best action? A. Notify the physician.
B. Administer acetaminophen 500 mg every 4 hours.
C. No action is needed; these findings are expected.
D. Administer acetaminophen 500 mg and request an order for an antianxiety agent.
A
Symptoms such as fever, tachycardia, tachypnea, and fluid collection can be indicative of an anastomosis leak. The physician should be notified immediately.
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A father brings his 1-year-old son to the clinic and states that when he kisses the child's cheek, it tastes salty. Which diagnostic test does the nurse educate the father on based on the father's statement?
A. Large bowel barium series B. Pancreatic enzyme analysis C. Pulmonary function studies D. Quantitative sweat chloride test
The nurse working in a physician's office recorded assessment data in the wrong patient's medical record about 1 hour ago. How should the nurse correct this error?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Black out the error with a marker and enter the new information. 2. Indicate the date and time the correction was made. 3. Indicate the reason the correction is being made by writing "wrong patient chart" along with the new information. 4. Enclose the corrected information in brackets to set it off from the original post. 5. Either initial or sign the correction.
The nurse is conducting a physical examination of a patient's heart. Where will the nurse place the stethoscope to best assess the S1 heart sound?
1. Left midclavicular line at the fifth intercostal space 2. Left sternal border at the fifth intercostal space 3. Right midclavicular line at the fifth intercostal space 4. Right sternal border at the third intercostal space
Which of the following is consistent with obturator sign?
A) Pain distant from the site used to check rebound tenderness B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion D) Pain that stops inhalation in the right upper quadrant