The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool
Which nursing action is the most appropriate?
a. Notify practitioner.
b. Measure abdominal girth.
c. Auscultate for bowel sounds.
d. Take vital signs, including blood pressure.
ANS: A
Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner.
You might also like to view...
Inspection of the peripheral vascular system should include
a. Assessing for edema using a tape measure b. Observing the color and temperature of the skin c. Noticing the hairiness or lack of hair on the extremities d. All of the above
The patient admitted to the mental health unit is concerned that health information given to the nurse remains confidential. What is the nurse's best response?
1. "We can keep the information just between the two of us if you prefer." 2. "I will share the information with staff members only with your approval." 3. "You can choose whether your physician needs this information for your care." 4. "If the information is important to your care, I will need to share it with the staff."
How many workers are needed to safely logroll a person?
a. Just 1 b. 2 or 3 c. 3 or 4 d. At least 4
While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?
a. Clamp the chest tube close to the insertion site. b. Set up a new drainage system, and connect it to the chest tube. c. Have the patient take and then hold a deep breath while the nurse reconnects the tube to the CDU. d. Place the disconnected end nearest the patient into a bottle of sterile water.