A client brought to the emergency department after an automobile accident tells the nurse that she
attended a cocktail party and consumed four drinks over the last hour.
Her blood alcohol level is 150
mg/dL (0.15 mg%) and she describes herself as "tipsy.". What conclusion can the nurse draw?
a. The client is intoxicated.
b. The client has a problem of alcohol dependence.
c. The client's blood alcohol is in the dangerous-to-life range.
d. Insufficient data are present to draw any conclusion.
A
The client's blood alcohol level indicates she is intoxicated. Because her behavior and the blood
alcohol level correspond, one can assume the client does not have a high tolerance to alcohol. Option
B is not a conclusion that can be drawn. Option C is not a true statement. The blood alcohol level for
coma and death is 0.40 to 0.50 mg%. Option D is incorrect. A conclusion can be drawn.
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A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?
A) Perform mechanical débridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.
The nurse is planning care for an older patient. Which factors does the nurse realize are affecting this patient's immune status?
Select all that apply. 1. environmental pollution 2. a chronic illness 3. presence of autoantibodies 4. nutritional status 5. quality of sleep and rest
Which is an example of an actual diagnosis?
a. Risk for Impaired Skin Integrity Related to Inability to Change Positions b. Potential for Enhanced Nutrition c. Fluid Volume Deficit Related to Nausea and Vomiting d. Risk for Infection Related to Indwelling Urinary Catheter
A client with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock
The nurse includes which of the following interventions in the client's plan of care to best address this issue? Select all that apply. 1. Utilize abdominal binder and thigh-high compression stockings. 2. Administer vasoactive agents and atropine as ordered. 3. Strictly monitor and document intake and output. 4. Administer anticoagulant medication as ordered. 5. Assess color, temperature, and size of extremities.