When assessing an adolescent who recently overdosed on acetaminophen (Tylenol), it is most important for the nurse to assess for pain in which area of the body?
A) Flank.
B) Abdomen.
C) Chest.
D) Head.
Answer: B) Abdomen.
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During assessment of an older adult, which finding does the nurse immediately report to the health care provider?
a. Yellowing or bluing of the sclera b. Lack of discrimination between green and violet c. An opaque, bluish-white ring within the outer edge of the cornea d. Pupil constriction in response to light oc-curring in 2 seconds
The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?
1. Document the findings. 2. Catheterize the client. 3. Massage the uterine fundus until it is firm. 4. Call the physician immediately.
A nurse is talking to the mother of an exclusively breast-fed African American 3-month-old infant who was born in late fall. Which supplement will the nurse recommend for this infant?
1. Iron 2. Vitamin D 3. Fluoride 4. Calcium
The nurse is reviewing the urinalysis results of an older adult patient admitted with elevated temperature and incontinence. Which urinalysis properties are indicative of an infection? (Select all that apply.)
a. Straw color b. Foul odor c. Trace glucose d. pH of 8.2 e. Specific gravity of 1.014