The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a crack-addicted mother. What would be the manifestations of this syndrome? (Select all that apply.)
a. Body tremors
b. Excessive sneezing
c. Hyperirritability
d. Drowsiness
e. Excessive appetite
ANS: A, B, C
The neonate with abstinence syndrome will have tremors, be hyperirritable and wakeful, have excessive sneezing or yawning, and have no appetite.
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A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, "When I wake up I am in pain." Which action should the nurse take?
a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client.
To assess the amount of pain medication needed by the patient who has bone cancer, but who has also been using heroin, the best approach is to:
1. tell the patient that getting his pain under control will be difficult because he uses heroin. 2. ask the pharmacist to help you compute the amount of pain medication that you think he will need. 3. try to use nonopioid medications so that you do not interfere with his heroin needs. 4. openly question the patient about his daily heroin use.
A patient has ascites caused by liver failure. Which finding should the nurse report for immediate follow-up?
A. Dyspnea B. Increased abdominal girth C. Jaundice D. Asterixis
Which of the following acronyms can be used to identify the steps of the evidence-based practice (EBP) process?
a. MYWAY b. ASKMME c. RIGHT d. ASKWHY