When the nurse formulates three nursing diagnoses for an adult patient hospitalized for abdominal surgery, the nurse has focused on the patient's
A) Medical record.
B) Actual health problems
C) Medical diagnosis
D) Past medical history
Ans: B
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A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
A) Expiratory wheezes B) Inspiratory wheezes C) Rhonchi D) Crackles
The nurse teaches a patient with tetraplegia or paraplegia which of the following guidelines related to bladder management?
A) Empty the bladder frequently. B) Consume 500 mL of fluid daily. C) Wear synthetic underwear. D) Concentrated urine should be reported to the physician immediately.
The nurse is preparing to review the secondary sources of data for a patient with glaucoma. Which diagnostic testing should the nurse anticipate to be included?
A. Tonometry. B. Refraction test. C. Ultrasonography. D. Fluorescein angiography.
The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says "I always bathe in the evening." Which action by the nurse is best?
a. Defer the bath until evening and pass on the information to the next shift. b. Tell the patient that daily morning baths are the "normal" routine. c. Explain the importance of maintaining morning hygiene practices. d. Cancel hygiene for the day and attempt again in the morning.