A patient with cirrhosis is experiencing hypertension, edema, and shortness of breath. What should the nurse identify as the patient's priority problem?
A. Insufficient fluid level
B. Too much bodily fluid
C. Problem with integumentary status
D. Problem with tissue perfusion
Answer: B
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A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client's nose and around the intravenous catheter. What action by the nurse is the priority?
a. Hold pressure over the client's nose for 10 minutes. b. Take the client's pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.
The patient at risk for GI hemorrhage should be monitored for which of the following signs and symptoms?
a. Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena
Which of the following nursing interventions would help strengthen a client's level of hope?
a. Leaving the client alone in the room b. Permitting the client to sit and cry quietly c. Providing resources to help the client work through a health problem or situation d. Encouraging the client to take an afternoon nap
Which evidence based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation?
1. Aseptic technique when performing oral hygiene 2. Administration of an H2 antagonist to prevent peptic ulcers 3. Elevation of the head of the bed to 15 degrees to prevent aspiration 4. Changing the ventilator circuit daily