The LPN/LVN is reviewing a patient's list of nursing diagnoses. Which diagnoses should the LPN/LVN identify as a priority for this patient?
a. Anxiety
b. Constipation
c. Deficient fluid volume
d. Ineffective airway clearance
ANS: D
D. Ineffective airway clearance is the highest priority, because it can be life-threatening. B. C. These diagnoses are important; however they are not immediately life-threatening. A. Anxiety is the lowest priority, because physiological needs must be addressed first.
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The nurse is teaching the parents of a child with a severe, chronic condition ways to promote growth and development. Which suggestion by the nurse is the most appropriate?
A. Allow interaction with peers, family, and community members. B. Ensure that the child is getting a nutritious diet and plenty of exercise. C. Insist that the public school include the child in all activities. D. Plot the child's growth and weight gain on growth charts monthly.
The school nurse is leaving campus after work when an accident occurs on the playground. The nurse responds and treats the injured students. Which standard of care would most likely determine liability?
1. The reasonably prudent school nurse 2. The reasonably prudent pediatric nurse 3. The reasonably prudent general duty hospital nurse 4. The reasonably prudent nurse in an emergency situation
The nurse is assessing a client during a routine physical examination. Which statement made by the client concerning the risk of oral cancer indicates that further teaching is needed?
a. "I will brush my teeth and floss regularly." b. "I will begin a smoking cessation pro-gram." c. "I can still use chewing tobacco since I stopped smoking." d. "I will limit my intake of alcoholic beve-rages."
When developing a plan of care for a 4-year-old preoperative client, the nurse selects which of the following appropriate outcomes for this client?
1. The client points to the FACES pain scale and utilizes it each time there is pain. 2. The client states understanding of the plan of care. 3. The client states understanding of the use of a PCA. 4. The client verbalizes why an indwelling catheter is needed.