What major complication do you suspect?
The patient is a 54-year-old man with chronic kidney disease (CKD) who has performed continuous ambulatory peritoneal dialysis (CAPD) four times a day, 7 days a week for the past 6 months. During your initial assessment, he reports abdominal pain, nausea with vomiting, and constipation. Assessment findings include diminished bowel sounds, rebound tenderness, and abdominal distention. Vital signs include heart rate:112/min and temperature: 101.8° F.
A. Hemorrhage B. Fibrin clot formation C. Peritonitis D. Exit site infection
C
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The nurse is caring for a patient receiving an antineoplastic medication IV. While the medication is infusing, the IV needle becomes dislodged and goes in to the tissue. What is the highest priority for this patient at this time?
a. Call the physician on call to report the occurrence. b. Inject medication immediately into the skin to counter the effect of the medication. c. Elevate the affected IV site and apply ice. d. Place the affected site into a dependent position.
Which of the following desired client outcomes will the nurse who is planning care choose for a client with the nursing diagnosis stress urinary incontinence related to sphincter incompetence?
1. The client will empty her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 10 to 15 seconds. 4. The client will stop the flow of urine when voiding.
A nurse prepares a care plan for a Japanese client. What is the most important rationale for including favorite or Japanese foods for this client?
A) It prevents malnutrition. B) It prevents clients from becoming agitated. C) It ensures the client's cooperation with scientifically based treatment. D) It conveys acceptance of the client's beliefs and identity.
The existence of regular, deep, and rapid respirations after a severe closed head injury is indicative of neurologic injury to what?
a. Lower midbrain b. Pontine area c. Supratentorial d. Cerebral area