The nurse instructs a patient with melanoma to "eat foods rich in protein and calories.". This intervention is most likely associated with which nursing diagnosis?
1. Impaired Skin Integrity
2. Hopelessness
3. Anxiety
4. Fluid Volume Deficit
1
Rationale 1: When planning care for a patient with Impaired Skin Integrity, interventions should include adequate caloric and protein intake for wound healing.
Rationale 2: Psychological alterations such as hopelessness cannot be managed by a diet rich in protein and calories.
Rationale 3: Psychological alterations such as anxiety cannot be managed by a diet rich in protein and calories.
Rationale 4: Fluid volume is not directly impacted by a diet high in protein and calories.
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IV fluid 250 mL was to be infused in 3 hours using 20 gtt/mL tubing. With 1 1/2 hours remaining, you find 200 mL left. Recalculate the flow rate in gtt/min. _____
a. 13 b. 17 c. 44 d. 33
When the nurse is evaluating the fluid balance for a patient admitted for hypervolemia associated with multiple draining wounds, the most accurate assessment to include is:
a) Skin turgor b) Daily weight c) Presence of edema
Because of the inflammatory process in RA, a pannus forms in the joint. What is a pannus?
a. scar tissue restricting the joint b. vascular granulation tissue in the joint c. necrotic tissue sloughing into the joint d. fluid encapsulated in the joint
Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday,
report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which of these orders should the nurse question? a. Electrocardiogram (ECG) STAT b. 500 mL 0.9% NS over 30 minutes c. Arterial blood gases (ABGs) STAT and repeat in 1 hour d. Oxygen 2 L/min via nasal cannula