The nurse has written the nursing diagnosis Risk for Injury for a diabetic pregnant patient. Interventions for this diagnosis include: Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply
1. Assessment of fetal heart tones.
2. Perform oxytocin challenge test, if ordered.
3. Refer the patient to a diabetes support group.
4. Assist with the biophysical profile assessment.
5. Develop an appropriate teaching plan.
1,2,4
Rationale 1: null
Rationale 2: Perform oxytocin challenge test (OCT)/contraction stress test (CST) and nonstress tests as determined by physician.
Rationale 3: Referring the patient to a diabetes support group is not appropriate at this time, and is more suitable for the nursing diagnosis Anxiety.
Rationale 4: The nurse assists the physician in performing a biophysical profile assessment.
Rationale 5: Developing an appropriate teaching plan is an intervention for Readiness for Enhanced Knowledge.
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The nursing care plan addresses discharge planning
1. When nursing outcomes and client goals are met 2. The first postoperative day 3. The day the client is admitted 4. After teaching is completed
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
A) Impaired gas exchange B) Collapsed bronchial structures C) Necrosis of the alveoli D) Closed bronchial tree
The nurse, caring for a patient with obstructive shock because of a pulmonary embolism, would implement which of the following orders FIRST?
1. normal saline infusion at 150 cc/hr 2. oxygen at 35 percent via endotracheal tube 3. obtaining chest x-ray and PTT 4. heparin infusion at 1,500 units/hr
A client diagnosed with hypertension is experiencing allergic rhinitis. The nurse realizes that the medication that would not be indicated for this client would be:
1. loratadine. 2. montelukast. 3. pseudoephedrine. 4. zafirlukast.