Basic Care and Comfort

The nurse is creating a tool to screen for patients who are risk for vitamin A deficiency. The nurse includes which conditions in the screening tool? Select all that apply.

The nurse notes the patient’s nails appear to curl upwards like spoons. Which statement by the nurse is most appropriate?

The patient undergoing continuous bladder irrigation (CBI) following a prostatectomy reports an extreme need to urinate. Which action by the nurse is most appropriate? 

At 48 hours postop from a prostatectomy, the patient is noted to have pink output from the continuous bladder irrigation (CBI) system. Which action by the nurse is most appropriate?  

The nurse reviews the patient’s 24-hour intake and output for the patient with continuous bladder irrigation (CBI). The CBI intake is 2000 mL and the output is 2600 mL. Which action by the nurse is most appropriate?  

The patient with short stature associated with Noonan syndrome is being considered for somatropin injections. The nurse ensures which test is performed before therapy is started? 

The nurse is providing preprocedural teaching for the patient scheduled for a cystectomy for bladder cancer. Which statement by the patient indicates teaching was effective? 

The patient with bladder cancer is scheduled for a cystectomy and creation of an internal ileal reservoir. Which statement by the patient indicates an understanding of the teaching?  

The patient has undergone a cystectomy with ureterosigmoidostomy. Which nursing interventions are included in the care plan? Select all that apply. 

The nurse has provided self-care teaching to the patient who has undergone radiation therapy for breast cancer. Which action by the patient indicates a need for further teaching?  

Which intervention is appropriate for the patient receiving chemotherapy for breast cancer? 

The nurse is evaluating the understanding of the patient who has been taught to perform a colostomy irrigation. Which action requires further teaching? 

The 3-year-old with sickle cell disease is preparing for discharge following a crisis during which the patient received several blood transfusions. The nurse is providing teaching regarding appropriate food choices for the child. Which foods, if selected by the parents, indicate a need for further teaching? Select all that apply.  

The nurse is providing health promotion teaching for the 22-year-old patient with phenylketonuria. Which food, if selected by the patient, prompts the nurse to intervene?  

The 78-year-old resident of a nursing home is brought to the emergency department for abdominal pain that is not responsive to oxycodone. She takes captopril, atenolol, lovastatin, and glyburide in addition to the oxycodone. Upon assessment, her abdomen is full and mildly tender. She has positive bowel sounds and reports passing gas but no stools for 96 hours. She denies anorexia or vomiting. A digital rectal examination is performed and stool is found in the rectum. The nurse anticipates being ordered to perform which intervention for this patient?  

The nurse is planning care for the 78-year-old patient with recurrent fecal impaction. The patient has prostate cancer that has metastasized to the bone. In addition to palliative chemotherapy, the patient receives a fentanyl transdermal patch and intravenous hydromorphone. The patient is neutropenic and thrombocytopenic. The nurse works with the provider to plan which intervention to manage the opioid-induced constipation and subsequent fecal impaction? 

The nurse notes the 4-day-old infant develops circumoral cyanosis while breastfeeding. Once the seal is broken and the neonate begins to cry, the cyanosis resolves and the child becomes pink. There are no nasal secretions and the neonate’s vitals are normal. Which action by the nurse is most helpful?  

The 12-hour-old neonate was born at 39 weeks to a G2P2 mother after an uncomplicated pregnancy and delivery. Slight oligohydramnios was noted during the pregnancy. The neonate has not urinated. Upon assessment, the nurse notes stable vital signs and suprapubic distention. The nurse contacts the provider to advocate for which initial intervention?