The nurse is providing care for a patient recovering from a hip replacement who has a history of respiratory disease. Place the following nursing diagnoses in order of priority (1–4)
A. _____ Risk for injury related to unsteady gait
B. _____ Knowledge deficit related to use of a walker
C. _____ Acute pain related to surgery
D. _____ Impaired gas exchange related to compromised respiratory system
ANS:
A. ANS: 4
B. ANS: 3
C. ANS: 1
D. ANS: 2
In a nursing plan of care, the patient's most urgent problem is listed first. According to Maslow's hierarchy of human needs, this usually involves a physiological need such as oxygen or water, because these are life-sustaining needs. If several physiological needs are present, life-threatening needs are ranked first, health-threatening needs are second, and health-promoting needs, although important, are last. In this case, ineffective breathing is a potentially life-threatening need and would be first; acute pain is the next most urgent need, followed by risk for injury which is less critical than pain because it is a potential problem rather than an actual problem; knowledge deficit would be last because it is health promoting and considered psychosocial rather than physical/physiological.
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The nurse is caring for a 13-year-old girl with delayed puberty. Which nursing diagnosis is appropriate for this child?
A) Ineffective family coping related to the child's disorder B) Inadequate nutrition related to the child's short stature C) Anticipated noncompliance related to long-term therapy D) Knowledge deficit related to the administration of estradiol
When doing manual ventilations during a code, the nurse would administer ventilations following which guideline?
a. Approximately 8 to 10 breaths per minute b. During the fifth chest compression c. Every 3 seconds or 20 times per minute d. While compressions are stopped
Which of the following observations would be made prior to administering a medication?
A. If the temperature dropped in a patient receiving acetaminophen for fever B. The patient is alert and able to swallow solid foods. C. The patient vomited immediately upon taking her medications. D. The patient reports relief of pain and is resting comfortably.
Patients require insurance counseling prior to accessing health-care services due to the following reason:
a. Many patients do not understand policy benefits and payment responsibility. b. Services may change across the beneficiary year. c. Copayments and deductibles may have been already met by the patient. d. Coding may need to be adjusted to meet the needs of the patient's benefits.