The nurse is caring for a 6-month-old child who has elbow restraints ordered. The nurse should:
a. Remove both restraints with supervision
b. Examine both limbs one at a time with the restraints off
c. Keep the restraints on until the physician orders them to be removed
d. Generously pad the restraints, but not remove them
B
Elbow restraints should be removed one at a time with supervision to examine the limbs and confirm that there is adequate circulation.
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The nurse is inserting a small-bore nasogastric tube. Which action by the nurse is appropriate when completing this procedure?
1. Removing the stylet prior to inserting the tube into the client's nose 2. Measuring from the tip of the client's nose to the xiphoid process to determine length of tube to be inserted 3. Checking the nares for patency prior to passing the catheter 4. Applying sterile gloves before beginning the procedure
Which organs are nonfunctional during fetal life?
a. Kidneys and adrenals b. Lungs and liver c. Eyes and ears d. Gastrointestinal system
The nurse is caring for clients on a neurologic floor. Which client goal is most appropriate for the acute phase of a neurologic injury?
A) The client will use the adaptive devices to assist with feeding. B) The client's vital signs will stabilize returning to baseline. C) The client's skin will remain clean, dry, and intact. D) The client will return to optimal level of functioning.
The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Pain is common. b. Weight loss is severe. c. Rectal bleeding is common. d. Diarrhea is moderate to severe. e. Anal and perianal lesions are rare.