An outcome for the nursing diagnosis of risk for injury that would be appropriate for both a
hospitalized client with delirium who misinterprets reality and a client with dementia who wanders
about his home is that the client will
a. remain safe in the present environment.
b. participate in self-care.
c. acknowledge reality.
d. communicate confusion.
A
Safety maintenance is the desired outcome of the nursing diagnosis. The other outcomes are not
directly related to the stated nursing diagnosis and may or may not be realistic for the clients
mentioned because so little is known of their conditions.
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The nurse is preparing an educational program on hemolytic anemia for the residents of an assisted living center. Which potential causes should the nurse include in the program? Select all that apply.
1. Chronic steroid therapy 2. Prolonged jaundice 3. Cephalosporin antibiotics 4. Exposure to toxic chemicals 5. Prosthetic heart valve placement
A toddler is admitted to the pediatric unit with presumptive bacterial meningitis. The initial orders include isolation, intravenous access, cultures, and antimicrobial agents. The nurse knows that antibiotic therapy will begin when?
a. After the diagnosis is confirmed b. When the medication is received from the pharmacy c. After the child's fluid and electrolyte balance is stabilized d. As soon as the practitioner is notified of the culture results
Order: Penicillin G procaine 300,000 units IM q 12h. The label on the vial reads 600,000 units per milliliter. How many milliliters will you administer?
1. 2 mL 2. 0.25 mL 3. 0.5 mL 4. 3 mL
The nurse practitioner orders a urine specific gravity for an athlete brought to the emergency department following a marathon for complaints of fatigue, elevated temperature, and confusion
When it returns, the report shows the urine specific gravity to be 1.039. She interprets this as a sign of: 1. Hyper hydration. 2. Euhydration. 3. Dehydration. 4. Water toxicity.