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. The most appropriate nursing action is to:
a. Notify the 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 plan of care.
You might also like to view...
What is the Healthy People 2020 goal for health disparities?
A. Achieve health equity, eliminate disparities, and improve the health of all groups. B. Reduce health disparities among Americans. C. Eliminate health disparities among Americans. D. Recognize health disparities among elderly.
A newborn is at GREATEST risk for meconium aspiration if he or she:
A) is large for his or her gestational age. B) requires positive-pressure ventilations. C) has respiratory depression at the time of birth. D) is born at more than 42 weeks' gestation.
The nurse is assessing an obese patient's lower leg and notes a small irregular-shaped ulcer over the medial malleolus with brownish discoloration. The patient reports that the "leg has been that way for a long time" What do these findings suggest to the nurse?
a. Varicose vein b. Venous stasis ulcer c. Phlebitis d. Raynaud's phenomenon
The portion of total ventilation that participates in gas exchange is known as
a. alveolar dead space. c. physiologic dead space. b. anatomic dead space. d. alveolar ventilation.