1. What assessment would be observed from the patient? 2. As you have performed gastric lavage, create an FDAR charting for this patient. DATA, ACTION and RESPONSE DATE/ TIME FOCUS
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- A nurse is performing digital removal of stool on a 74-year oldfemale patient with a fecal impaction. During the procedure thepatient tells the nurse she is feeling dizzy and nauseated, andthen she vomits. What should be the nurse’s next action?a. Reassure the patient that this is a normal reaction to theprocedure.b. Stop the procedure, prepare to administer CPR, and notifythe physician.c. Stop the procedure, assess vital signs, and notify thephysician.d. Stop the procedure, wait five minutes, and then resume theprocedure.A nurse is assessing a client who has acute pancreatitis. Which of the following findings should the nurse expect?A.HypertensionB.Hyperactive bowel soundsC.Peripheral edemaD.Periumbilical discolorationThe nurse is administering an intravenous aminoglycoside to a patient who has had gastrointestinal surgery. Which nursing measures are appropriate? (Select all that apply.)a )Report a trough drug level of 0.8 mcg/mL, and hold the drug.b) Enforce a strict fluid restriction.c )Monitor serum creatinine levels.d )Instruct the patient to report dizziness or a feeling of fullness in the ears.e) Warn the patient that the urine may turn darker in color
- The nurse is revieing the history of a patient ho ill be starting the triptan sumatriptan (Imitrex) as part of treatment for migraine headaches. Which condition, if present, may be a contraindication to triptan therapy?a) Cardiovascular diseaseb) Chronic bronchitisc )History of renal calculid )Diabetes mellitus type 2The nurse is caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. Which of the following actions should the nurse take? Click the exhibit button for additional client information. 01. 02. Check the amount of gastric residual. Administer prescribed prochlorperazine. О3. Clamp the NG tube and discontinue the tube feedings. 04. Administer prescribed oxygen at 4 L/min via nasal cannula.Which assessment is essential for the nurse to make in preparing a pt for an intravenous pyelogram? a) Determine if the patient has an allergy to iodine. b) Check date of the patients last bowel movement c) Obtain the patient baseline body temperature orally d) Ascertain when the patient last had an x-ray asap
- "A patient is admitted with severe dehydration secondary to gastroenteritis. Describe the nursing assessments and interventions required."A nurse is developing a plan of care related to preventionof pressure ulcers for residents in a long-term care facility.Which action would be a priority in preventing a patient fromdeveloping a pressure ulcer?a. Keeping the head of the bed elevated as often as possibleb. Massaging over bony prominencesc. Repositioning bed-bound patients every 4 hoursd. Using a mild cleansing agent when cleansing the skinAs a nurse on a general medical floor, the RN has received a new admit. Review the client data provided. Richard Henderson 58 years old Male Admit diagnosis: GI bleed History: no surgical history Medical history: Gastritis & GERD Medications: Prilosec 40 mg PO daily, Atenolol 25 mg PO BID, Fiber daily, Alka Seltzer PO – states he takes this at least daily. Report from physician’s office: Mr. Henderson arrived to the physician’s office today for a complaint of increasing abdominal pain. He states that he is now throwing up coffee-ground emesis. He states that he didn’t take his BP medication this morning because he was dizzy. The physician is admitting him with a diagnosis of GI bleed with an EGD scheduled for tomorrow. He is NPO, and has a 22G IV lock in the left forearm. Last set of vital signs BP 106/60 mm Hg, HR 98 beats/min, RR 20 breaths/min, Temp. 98.8 degrees F, P.O. 90% on room air. He last vomited about 45 minutes ago with a small amount of dark coffee-ground emesis.…
- The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? A. The patient must maintain a low-calorie diet. B. The patient must maintain a high protein/low carbohydrate diet. C. The patient should limit sweets and sugary drinks. D. The patient should limit fatty foods.A nurse is assessing a client with the internal(intestinal) obstruction which of the following would the nurse expect when viewing lab information? SATA a) Increased Hematocrit b) Loss of electrolyte c) Emesis of fluid d) Fluid overload e) Accumulation of the fluid below the obstruction 59. A nurse is caring for a child that has acute cholecystitis which of the following should the nurse anticipate when viewing the client's chart? a) Increase white blood cell count. b) Normal liver function c) Decrease temperature. d) Decrease white blood cell count. 61. Which technique should the nurse when assessing the dorsalis pedis a) Cover your finger around the medialis b) Press deeply with two fingers c) Press firmly …… d) Use a very light touch 65. Which site is appropriate for palpation for the popliteal pulse? a) At the wrist b) In front of the ear c) Below the knee d) At the inner thighThe nurse is planning care for a patient with cirrhosis. For which of the condition the nurse would place the patient on bleeding precautions?A. EncephalopathyB. Low vitamin KC. Elevated liver enzymesD. Hepatorenal syndromeExplain please