A patient at 37 weeks gestation is being seen in the prenatal clinic. Where would the nurse expect the fundal height to be palpated?
A) At the xiphoid process
B) At a point between the umbilicus and the xiphoid
C) At the umbilicus
D) At a level directly above the symphysis pubis
A
At the xiphoid process
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The nurse works on a medical-surgical unit. Which clients will require a rapid assessment? Select all that apply
1. The client had an open appendectomy 2 days ago and is preparing to be discharged today. 2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. 3. The client has just been received from the Post Anesthesia Care Unit. 4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. 5. The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93% on room air this morning to 87%.
The nurse teaches the patient who has experienced toxic shock syndrome (TSS) 2 months postpartum which of the following general guidelines?
A) Use of superabsorbent tampons is not recommended. B) Tampons may be left in place up to 4 hours. C) A diaphragm or cervical cap may be used during menses. D) TSS is not associated with postpartum bleeding as much as with menses.
The nurse assisting with prioritizing nursing diagnoses would select which of the following as the highest priority?
1. Impaired adjustment 2. Acute pain 3. Risk for imbalanced body temperature 4. Ineffective airway clearance
A patient with seizure activity is receiving intravenous phenytoin (Dilantin). Which nursing interventions are indicated?
1. Assess deep tendon reflexes. 2. Closely monitor serum potassium. 3. Monitor injection site frequently. 4. Turn and reposition every hour. 5. Monitor for the development of rash