During a morning assessment, the nurse observes that a patient displays bulging flanks when supine with the knees flexed. Which action should the nurse take next?
a. Measure the patient's abdominal girth.
b. Auscultate each quadrant of the abdomen for 5 minutes.
c. Document the finding.
d. Notify the charge nurse.
A
The nurse's initial assessment indicates fluid accumulation. The nurse needs to obtain more in-formation, first measuring abdominal girth. The nurse can then percuss from the umbilicus to the flanks to detect fluid shifts, and document all findings. The nurse will only auscultate bowel sounds for 5 minutes in each quadrant if bowel sounds are not heard before then. It is unneces-sary to notify the charge nurse at this time.
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A) Remove the antiembolism stockings nightly and reapply by 8 AM. B) Place the antiembolism stockings on the lower extremities as tolerated. C) Remove the antiembolism stockings briefly every 8 hours. D) Apply the antiembolism stocking prior to ambulation daily.
An older patient is being assessed by the nurse. Which finding does the nurse consider abnormal when assessing the patient's risk for fall?
a. Use of an assistive device b. Wearing glasses c. Failure of the Get Up and Go test d. Negative Romberg's test
The esophagus is a structure that
a. produces and releases digestive enzymes but not hormones. b. does not produce digestive enzymes but does release hormones. c. does not produce or release digestive en-zymes or hormones. d. produces only small amounts of digestive enzymes or hormones.
A health care worker tells a nurse, "It does no good to try to teach those Medicaid clients about nutrition because they will just eat what they want to no matter how much we teach them." Which of the following is being demonstrated by this statement?
a. Cultural imposition b. Ethnocentrism c. Racism d. Stereotyping