Which of the following nursing diagnoses would explain the purpose of the using a self-sheathing stylet catheter?
1. Risk for Injury
2. Risk for Fluid-Volume Deficit
3. Risk for Infection
4. Risk for Altered Nutrition
Risk for Injury
Rationale: Risk for Injury is the nursing diagnosis that explains the purpose of the self-sheathing catheter. It is engineered with a safety mechanism that causes the needle to become encased in a protective chamber upon removal from the inserted catheter, thus preventing a needle-stick injury. A self-sheathing stylet catheter use does not reflect fluid-volume status and is not used to prevent infection. The use of a self-sheathing stylet catheter is not related to nutritional status.
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The nurse is inspecting a client's chest and upper extremities. Which of the following would be the appropriate method for the nurse to assess these body areas?
1. Examine the right arm, the chest, and then the left arm. 2. Examine the left arm, the chest, and then the right arm. 3. Examine the left arm, the right arm, and then the chest. 4. Examine the chest and examine the arms at the conclusion of the exam as the client is re-dressing.
A patient inadvertently took an excessive dose of warfarin (Coumadin) and was immediately treated with IV vitamin K (Phytonadione). The symptoms that would most concern the nurse after administration of vitamin K are
a. mild pruritus, pulse of 92. b. respirations of 32, bronchoconstriction, O2 sats of 83%. c. prolonged sensitization to warfarin (Coumadin). d. blood pressure of 107/52 and bleeding gums.
What assessment finding would you expect during one respiratory cycle in a client who has a paralyzed left phrenic nerve?
A. Left side of the diaphragm would fail to rise during inhalation and would be un-affected during exhalation. B. Left side of the diaphragm would fail to rise during exhalation and would be un-affected during inhalation. C. Left side of the diaphragm would fail to flatten during inhalation and would be unaffected during exhalation. D. Left side of the diaphragm would fail to flatten during exhalation and would be unaffected during inhalation.
Your client is talking about suicide after losing his wife in an automobile accident. He has been treated for depression for the past 5 years and has resumed drinking since her death. He is angry with God for taking her
What nursing diagnosis would be most appropriate? 1. Ineffective coping 2. Readiness for enhanced spiritual well-being 3. Risk for spiritual distress 4. Spiritual distress