After an assessment the nurse is concerned that a patient is experiencing cor pulmonale associated with right-heart failure. What finding led the nurse to make this clinical decision? Select all that apply.
A. Nasal drainage
B. Distended neck veins
C. Cyanotic nail beds
D. Ankle edema
E. Ruddy cheeks
Answer:
B. Distended neck veins
C. Cyanotic nail beds
D. Ankle edema
E. Ruddy cheeks
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Which nursing intervention should be included in the plan of care for a patient dying of cancer?
a. Encourage at least one family member to remain at the bedside at all times. b. Follow-up with other healthcare team members during weekly meetings. c. Avoid discussing the dying process with family (to reduce sadness). d. Encourage family members to participate in care of the patient when possible.
When preparing nutritional instruction, which of the following pregnant clients would the nurse consider highest-priority?
1. 30-year-old G2 2. 22-year-old primigravida 3. 35-year-old G4 4. 15-year-old nulligravida
A child with growth hormone deficiency will be receiving a daily subcutaneous injection of biosynthetic growth hormone. The parents are being trained to administer the injection
Which instruction is most important for the nurse to include in parent instructions? 1. Avoid cleaning the area with alcohol before giving the injection. 2. Use only the legs for injection sites. 3. Delay giving the injection by 1 day if the child becomes upset. 4. Rotate the injection sites.
When the nurse observes melena, she is aware that a minimum of _____ to _____ mL of blood has been deposited into the GI tract
a. 25; 50 b. 50; 75 c. 75; 100 d. 100; 120