The nurse is planning care for an older patient with heart failure who is experiencing shortness of breath. Upon assessment the patient stated the inability to purchase medication because of financial limits
Which nursing diagnoses will be of the greatest initial importance when planning care? 1. Fluid Volume Excess
2. Fatigue related to shortness of breath
3. Activity Intolerance related to shortness of breath
4. Ineffective Management of Therapeutic Regime related to inability to purchase medications
1
Rationale: Although all diagnoses listed are appropriate for this situation, Fluid Volume Excess is the priority diagnosis for this patient.
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Put the following nursing assessments of a toddler in the best order for the nurse to proceed (from first assessment to last assessment). Standard Text: Click and drag the options below to move them up or down. Choice
1. Auscultation of chest Choice 2. Examination of eyes, ears, and throat Choice 3. Palpation of abdomen Choice 4. General appearance
During a health assessment the nurse learns that a client has no family, and lives with a roommate who is a close friend. What should the nurse conclude about this client's family structure?
1. The client and roommate constitute a family. 2. Two friends live in the same space. 3. The functioning of this group is different from normal. 4. The client is a homosexual.
Biobrane was applied to a patient's partial-thickness burn injury. Two weeks later, the nurse notices that the Biobrane is separating from the burn wound. The appropriate nursing intervention when this separation occurs is to:
A) Reinforce the Biobrane dressing with another piece of Biobrane B) Remove the Biobrane dressing and apply a new dressing C) Trim away the separated Biobrane D) Notify the physician for further emergency related orders
The nurse is reviewing safety information provided through the staff development department. This information would include information about all of the following, EXCEPT:
a. back injury. b. latex allergy. c. toxic reaction to chemotherapeutic agents. d. infections following dressing changes.