In end-stage liver disease, hypervolemia is always a problem. What nursing interventions would be most appropriate when caring for these patients? (Mark all that apply.)
A) Administering diuretics
B) Giving pain medications
C) Implementing fluid restrictions
D) Teaching nutrition
E) Enhancing patient positioning
Ans: A, C, E
Feedback: Pulmonary compromise, which is always a potential complication of ESLD because
of plasma volume excess, makes prevention of pulmonary complications an important role for the nurse. Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize pulmonary function.
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An appropriate goal for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired physical mobility is:
a. the patient will interact with others. b. the patient will ambulate to the bathroom with assistance. c. the patient will have no skin breakdown. d. the patient will have a physical therapy consult.
The biggest difference between the nursing process and many psychotherapeutic approaches is:
a. identified outcomes b. interventions based on theory c. assessment of client's needs d. evaluation of effectiveness
A nurse is caring for a dying male client who belongs to an organized religious group. How can the nurse best help the client to draw strength from his religious faith?
A) Limit visitors to immediate family during prayer sessions. B) Arrange for individuals from the client's religious group to pray with the client. C) Have the hospital chaplain visit with the client each day. D) Find out what religious materials would be of help to the client.
What would be a nursing priority when assessing a patient who weighs 250 pounds and stands 5' 3" tall?
A) Assess the HDL/LDL levels B) Obtain an electrocardiogram daily C) Assess blood pressure with a large cuff D) Begin patient teaching regarding a low fat diet