S2 and S3 S3 and S4 S4 and S1 S1 and S2
The nurse knows which of the following body systems is responsible for the production of somatostatin?
endocrine system gastrointestinal system lymphatic system cardiac system
A 54-year-old female is brought into the ED by her spouse. The client’s spouse tells the nurse the client has been experiencing muscle stiffness, increased perspiration, and anxiety. The nurse obtains bloodwork as ordered by the physician, including a complete blood count and a comprehensive metabolic panel. For which result should the nurse immediately notify the physician?
calcium 7.2 mg/dL alkaline phosphatase 120 IU/L sodium 143 mEq/L creatinine 0.8 mg/dL
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
perform perineal care using sterile technique irrigate daily with 60 cc normal saline restrict fluids to 1,500 cc/day stabilize the catheter on the abdomen
A client is receiving patient-controlled analgesia following surgery. Which statement by a family member indicates that the nurse needs to do further teaching?
“We will call you if the pump starts beeping.” “We will call you if she becomes oversedated.” “Nausea is not an allergic reaction to the medication.” “If she is asleep, we will press the button for her so she won’t wake up in pain.”
A client has orders for placing a small-bore nasoenteric tube. Which finding in the health history would prompt the nurse to notify the prescriber before placing tube?
small-bowel lesion basilar skull fracture acute coronary syndrome use of diabetic insulin pump
In caring for a critically ill client with a nasogastric tube (NGT) for enteral feeding, which action by the nurse demonstrates competency in NGT care? Select all that apply.
The nurse checks gastric residual every 4 hours for continuous feedings. The nurse maintains the client in a low Fowler’s position during feeding. The nurse checks gastric residual before each bolus or intermittent feeding. The tubing is changed every 48 hours or when the bag appears visibly soiled. The nurse returns the residual to the…
The nurse is caring for a client with a wound with purulent, foul-smelling drainage. A wound culture is ordered. Which describes the correct collection technique?
clean the wound with normal saline before obtaining specimen allow 24 hours for antibiotic therapy to take effect before sampling obtain the specimen from the drainage at the bottom of the wound culture the outer surface around the wound before collecting exudate
A client with an upper GI bleed is about to undergo gastric lavage by the nurse. Which action by the nurse is correct in performing this procedure?
instill 200 to 300 mL of a prewarmed solution instill 400 to 600 mL of a room-temperature solution position the client on the right side during the procedure manually withdraw the solution until clear or light pink with no clots
A 34-year-old client is receiving an IM injection of ceftriaxone (Rocephin) for a urinary tract infection. Which is correct regarding IM injections?
A 1-inch-long 25-gauge needle should be used. The injection should be given at a 45-degree angle. The injection should be given at a 90-degree angle. A bleb should form on the skin’s surface following injection.