During which step of the nursing process is a nursing diagnosis for the patient developed?
A. Assessment
B. Analysis
C. Planning
D. Intervention
E. Evaluation
B
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You are on triage duty in the emergency department (ED) when a patient presents to the ED with symptoms indicative of a myocardial infarction (MI)
The patient informs you that these symptoms have been occurring over the last 4 to 5 days. Which diagnostic study do you expect the physician to order to diagnosis an MI? A) Myoglobin levels B) Creatine kinase (CK) and its isoenzyme CK-MB C) Troponin T and I D) Lactic dehydrogenase and its isoenzymes
One of the nursing actions includes turning, coughing, and deep breathing the client every 2 hours; what assessment is needed to validate the effectiveness of these actions?
1. Assessment of bilateral lung sounds 2. Documenting the blood pressure to compare the trends 3. Monitoring intake and output 4. Assess carotid pulses for bruits
When the client arrives in the intensive care unit following CABG surgery, the nurse obtains the reports from laboratory work including chemistries, a complete blood count (CBC), arterial blood gases (ABGs), and a chest x-ray; an ECG should be done
as soon as possible. The rationale for obtaining this data is: 1. To establish a baseline for future assessments. 2. To provide the client's family with the information. 3. To provide fellow nurses with the information. 4. To report to the surgery nurses.
While caring for a patient with a spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every 2 to 3 minutes while searching for the cause in order to prevent loss of consciousness or death. By completing these interventions, which health problem is the nurse preventing as the most dangerous complication of autonomic dysreflexia?
A. Elevated blood pressure B. Hypoxia C. Tachycardia D. Bradycardia