The nurse is caring for a child who is being evaluated for a possible nephroblastoma. Which nursing intervention would be important for this child?
A) Monitor for protein in the urine at each voiding
B) Protect the child from having the abdomen palpated
C) Check blood pressure every two hours
D) Measure the child's intake and output every hour
Ans: B
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A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex
The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? "If I:
1. "Were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured." 2. "Develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 3. "Want to become pregnant again, I will have to plan on being on bedrest for the whole pregnancy." 4. "Have bleeding in the third trimester of my next pregnancy, I might rupture membranes again."
An obtunded patient is admitted to the emergency department after ingesting a known poison. What must a nurse do to assist with a gastric lavage?
A) Place the patient in a semi-Fowler's position. B) Discard aspirate into the toilet. C) Instill the antidote before aspirating stomach contents. D) Inspect the oral cavity for loose teeth.
The nurse is working with a patient receiving oxygen. What can the nurse delegate to nursing assistive personnel (NAP) during the administration of oxygen?
a. Adjusting the flow rate of the oxygen b. Reporting changes in patient's behavior c. Instructing the patient about oxygen at home d. Assisting during endotracheal intubation