The nurse is documenting data obtained from the interview and physical assessment. This information would be documented on the:
a. nursing plan of care.
b. progress notes.
c. nursing admit assessment.
d. patient education record.
ANS: C
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A nurse identifies a nursing diagnosis of impaired urinary elimination related to urinary tract infection. When developing the plan of care, which of the following would be most important for the nurse to do first?
A) Develop a schedule for bladder emptying B) Encourage fluid intake C) Assess usual voiding patterns D) Monitor intake and output
The nurse would instruct a client with frequent bouts of diarrhea to:
A) Note the precipitating event. B) Decrease fluid consumption. C) Increase fiber in the diet. D) Change her daily routine.
Who is the legal next of kin in the consent process?
What will be an ideal response?
The presence of arterial insufficiency is suspected during an inspection of the lower extremities when the nurse observes:
1. Increased hair growth 2. Cooler skin temperatures 3. Marked edema 4. Brown pigmentation