A patient in intensive care after a severe head injury has developed diabetes insipidus. What nursing assessment is the most important?
A) Vital signs
B) Cardiac pattern
C) Fluid balance
D) Level of consciousness
C
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The nurse is caring for a couple who have just learned that their infant has a genetic disorder. Which of the following would be least appropriate for the nurse at this time?
A) Actively listen to the parents' concerns. B) Teach the parents about the child's medical needs. C) Provide time for the parents to ask questions. D) Offer suggestions for support services.
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best?
a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.
A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?
a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.
A young woman had just learned of the accidental death of her husband. She begins to cry and states, "It's not fair! How could he do this to me?" This remark is assessed as:
a. A plea for help b. An explosive episode c. An expression of anger d. Fear of making decisions alone