The nurse is caring for a patient 23 hours after abdominal surgery. Which finding would require the nurse to take action?
a. Report of flatus
b. Lack of appetite
c. Abdominal distention
d. Hypoactive bowel sounds in four quadrants
ANS: C
Distention could indicate paralytic ileus which is a postoperative complication. A. B. D. These are normal postoperative findings.
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A nurse caring for a client who is receiving warfarin (Coumadin) will monitor for signs of bleeding if which of the following thyroid hormone-regulating drugs is initiated? Select all that apply
A) Propylthiouracil (PTU) B) Desiccated thyroid (Armour Thyroid) C) Liotrix (Thyrolar) D) Methimazole (Tapazole) E) Liothyronine (Triostat)
With regard to the nutrient needs of breastfed and formula-fed infants, nurses should be aware that:
a. Breastfed infants need extra water in hot climates. b. During the first 3 months, breastfed infants consume more energy than formu-la-fed infants. c. Breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months. d. Vitamin K injections at birth are not needed for infants fed on specially enriched formula.
The nurse has instituted bedtime routines for patients with dementia in a long-term care facility. What assessment findings best indicate the program is effective?
a. Patients are more alert and oriented during the day. b. Patients fall asleep within 20 to 30 mi-nutes of going to bed. c. Patients appear happier and more inter-ested in activities. d. Patients on diuretics awake less often during the night.
The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Tensilon). Evaluation of the results indicates that the test is positive
Which of the following would be the expected response noted by the nurse? 1. Joint pain for the next 15 minutes 2. A decrease in muscle strength within 1 to 3 minutes 3. An increase in muscle strength within 1 to 3 minutes 4. Feelings of faintness or dizziness for 5 to 10 minutes