A patient is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base a teaching plan?
A) Impaired Skin Integrity C) Impaired Urinary Elimination
B) Risk for Deficient Fluid Volume D) Urinary Retention
B
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A woman who is 8 months pregnant is being assessed on a routine clinic visit. Which assessment findings require further assessment and treatment?
A) Blood pressure increased by 10 points from previous visit B) Blood pressure 150/95 mm Hg C) 1+ edema of lower extremities D) Urine output 750 mL in 24 hours
The nurse auscultates the fetal heart rate (FHR) and determines a rate of 152 . Which nursing intervention is appropriate?
a. Inform the mother that the rate is normal. b. Reassess the FHR in 5 minutes because the rate is too high. c. Report the FHR to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast.
Which cardiac complication does the nurse anticipate in the patient with advanced COPD?
A) Cor pulmonale B) Left-sided heart failure C) Pericarditis D) Hypertension
Which statement is true regarding goals and expected outcomes?
a. Goals focus on long-term needs and expected outcomes focus on short-term needs. b. A goal is a broad statement of desired changes that need not be written in behavioral terms. c. An expected outcome is a specific statement that describes the methods through which the goal will be achieved. d. Long-term goals focus on the etiology com-ponent of the nursing diagnosis.