The nurse caring for a leukemic child receiving chemotherapy notes that the child's abdomen is firm and slightly distended. Also, there is no record of a bowel movement for the last 2 days. These assessment findings suggest the possibility of:
a. Peripheral neuropathy
b. Stomatitis
c. Myelosuppression
d. Hemorrhage
A
Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensation in the bowel.
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In the emergency department, a patient's vital signs are: BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow
The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic overdose. Select the priority outcome. a. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. b. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. c. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields. d. The patient will demonstrate effective coping skills within 1 week of hospitalization. e. The patient will identify community resources for treatment of substance abuse.
The nurse checks the laboratory report on a client who recently had a spinal tap. Which cerebral spinal fluid (CSF) content should be of concern to the nurse?
1. High water content 2. Few white blood cells 3. High glucose content 4. Many red blood cells
A person would be most likely to produce excessive ketones if his or her food intake that day consisted only of
a. green salad with oil and vinegar dressing. b. refried pinto beans and rice. c. cheeseburgers and French fries. d. fried eggs with bacon and hash brown potatoes.
Some workers accidentally cause an electrical fire when installing a new piece of equipment in the intensive care unit. A patient is on a ventilator in the next room. What is the nurse's priority action?
a. Pull the fire alarm. b. Attempt to extinguish the fire. c. Call the physician to obtain orders to take the patient off the ventilator. d. Use an Ambu-bag and remove the patient from the area.