During a physical assessment of an at-risk patient, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of:
1. euglycemia.
2. rheumatic fever.
3. pneumonia.
4. cardiac decomposition.
4
1. Incorrect. Euglycemia is a condition of normal glucose level. These symptoms indicate cardiac decomposition.
2. Incorrect. Rheumatic fever can cause heart problems, but does not present these symp-toms, which are of cardiac decomposition.
3. Incorrect. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which are of cardiac decomposition.
4. Correct. Symptoms of cardiac decomposition may appear abruptly or gradually.
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To avoid committing errors in the nursing diagnostic process, the nurse should:
a. limit the amount of assessment data. b. assure that interpretation of data is based on nursing and not on the medical diagnoses. c. consult with a physician to make sure they are interpreting data correctly. d. compare the data collected with a medical diagnostic resource.
The nurse cares for a client with chronic alcohol abuse. Which laboratory finding does the nurse recognize as evidence of liver damage?
A) Albumin 3.5 g/dL B) ALT 50 unit/L C) ALP 45 unit/L D) AST/SGOT 30 unit/dL
The nurse is caring for a client receiving intravenous (IV) chemotherapy. The nurse notes the leakage of the chemotherapeutic drug from the vein into the surrounding tissues and is aware that this is which complication?
a. invasion c. extravasation b. extraction d. intrusion
The client, a 70-year-old woman who has mild congestive heart failure, asks when she should get a flu shot. What is the nurse's best response?
A. "If you got a flu shot last year, you need to make sure that you get the new shot exactly 1 year later." B. "You should get a flu shot early in the fall so that you make enough antibodies before the flu season arrives." C. "Since we don't know if the flu will come this year, you should wait until an out-break of flu in our area is reported." D. "Because flu shots are good for five years at a time, if you got a flu shot last year you do not need to get another one this year."