A nurse is caring for a patient with a gastrostomy tube. Th…

 A nurse is caring for a patient with a gastrostomy tube. The order set for the gastrostomy tube and enteral feedings can be found below.   Water Flush   Bolus with 200 mL of tap water four times per day   Residuals    If residual is < 100 mL, re-instill and continue with ordered feedingIf residual is 350 mL, discard residual, hold tube feeding, and contact provider.   Tube Feeding   Replete Fiber 50 mL/hour continuously

A diabetic client who is well controlled with insulin inject…

A diabetic client who is well controlled with insulin injections has been NPO since midnight before having a mastectomy. The nurse notes that no preoperative orders are written regarding the client’s daily insulin dose. What is the most appropriate action by the nurse?

Mr. F is a 45 yom who was diagnosed with Guillain Barre’ Dis…

Mr. F is a 45 yom who was diagnosed with Guillain Barre’ Disease one month ago. He presents with generalized muscle weakness in all extremities and trunk, along with impaired balance and sensory loss which is greater in the LE’s. The PT orders are for the patient to be tested for strength in hip flexion at this time. The patient can flex his hip against gravity, but cannot take any resistance. Which of the following grades are most appropriate for this patient?

You are preparing to measure a patient’s elbow extension by…

You are preparing to measure a patient’s elbow extension by first moving them passively through the available range. At the end of the range you feel a solid “thunk” as the movement abruptly comes to a halt at full extension. Which term best describes this end feel?

A patient has been admitted to a medical-surgical unit with…

A patient has been admitted to a medical-surgical unit with complaints of shortness of breath and a diagnosis of acute hypoxic respiratory failure secondary to pneumonia. Vital signs are below. Upon assessment, the nurse finds course crackles in all lung lobes with diminished lung sounds in the bases. Patient denies pain, but states: “I just can’t catch my breath.”   HR BP RR SpO2 Temperature   94 144/85 26 90%(6 liters, nasal cannula) 37.6 degrees C       Physician Orders    General:Utilize an appropriate oxygen delivery device to maintain SpO2 greater than 94%Notify physician if O2 saturation < 90% or respiratory rate > 30/minIncentive spirometry every hour while awakeElevate the head of the bed 30–45 degrees Lab:Arterial Blood Gases (ABG) every 6 hours and PRN for respiratory status changesCBC with differential dailyBasic Metabolic Panel (BMP) dailySputum culture and sensitivity x 1 STATChest X-ray in 48 hours to assess for resolution or progression Medications:IV 0.9% Normal Saline at 75 mL/hrAzithromycin 500 mg IV once dailyAcetaminophen 650 mg PO every 4-6 hours PRN for fever > 38°CMorphine 2 mg IV every 2 hours PRN for severe dyspnea or pain (monitor respiratory status closely)Enoxaparin 40 mg SC daily (if no contraindications) The nurse raises the head of bed to semi-fowler’s position. What physician order should the nurse implement next?