A client returns to the nursing unit after laparoscopic surgery. The nurse prepares to take the client's vital signs at several intervals, including: Standard Text: Select all that apply
1. Every 15 minutes for first hour.
2. Every 30 minutes for second and third hours.
3. Every hour for fourth through seventh hours.
4. Every 30 minutes for three hours.
5. Every four hours from return from surgery.
1,2,3
Rationale: The nurse takes vital signs every 15 minutes for 1 hour after surgery, if vital signs remain stable.
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The nurse is caring for a patient with reduced perfusion to the extremities. The nurse evaluates the patient and finds the response to therapy is not optimal. What lifestyle change does the nurse suspect is contributing to the lack of response?
a. Following a vegetarian diet b. Taking daily brisk walks c. Ingesting 1,500 mL of fluid per day d. Smoking cessation when the diagnosis was received
What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that "When I'm busy, I can't always take the time to go to the bathroom."
1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic.
A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal range for this client, and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature?
a. Add 1°F to 100.8°F to obtain an oral equivalent. b. Add 2°F to 100.8°F to obtain a rectal equivalent. c. Obtain a rectal temperature reading. d. Obtain a tympanic membrane reading.
Choose the nursing diagnosis that would be most appropriate for a patient having ear surgery:
1. Disturbed body image 2. Risk for injury 3. Acute confusion 4. Ineffective protection