Your 68-year-old client needs balanced suspended traction for a fracture of the right femur with a stage II pressure ulcer measuring 2×3 cm on the left buttock. Which of the following nursing diagnoses would be most appropriate for the pressure ulcer?
1. Impaired tissue integrity
2. Body image disturbance
3. Hopelessness
4. Impaired skin integrity
ANS: 4
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An IV is regulated at 40 gtt/min. The administration set delivers 60 gtt/mL. In 5 hours, the client will have received _______________
a. 200 mL b. 400 mL c. 300 mL d. 500 mL
The nurse is instructing the client on the proper way to self-administer nystatin. The client tells the nurse that he has been simply drinking a small amount of the medication from the bottle
The nurse explain to the client that the medication dosage should consist of 1 to 2: a. teaspoons, swished and then swallowed. b. teaspoons, swished and then expelled. c. ounces, swallowed twice daily. d. ounces, used to swab the oral cavity.
Which assessment findings indicate the treatment for a client prescribed an erythropoiesis-stimulating factor is successful?Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
A. The client's hemoglobin is increased. B. The client reports less shortness of breath on exertion. C. The client has not had an episode of epistaxis in over 3 weeks. D. The client reports enjoying a light exercise. E. The client has not had a fever since treatment began.
You respond to a call for an unresponsive diabetic. Upon arrival, you find a 23-year-old female unresponsive on her couch. During your assessment, you determine that her blood glucose level is 38 mg/dL. You attempt to start an IV, but are unsuccessful after several attempts. Which of the following routes could be used as a last resort to administer 50% dextrose?
A. Rectal B. Subcutaneous C. Intralingual D. Oral