An 8-month-old has a ventricular septal defect. Which nursing diagnosis below would best apply?
A) Ineffective airway clearance related to altered pulmonary status
B) Ineffective tissue perfusion related to inefficiency of the heart as a pump
C) Impaired gas exchange related to a right-to-left shunt
D) Impaired skin integrity related to poor peripheral circulation
B
You might also like to view...
At Hospital Ajax, there has been a 20% increase in instruments and sponges being left in patients during surgery and surgeries on the wrong limbs. These are known as:
a. Sentinel events. b. Medically sensitive events. c. Nurse-sensitive events. d. Never events.
A patient in the intensive care unit is at risk for developing malnutrition. Indirect calorimetry is planned to estimate the patient's caloric needs. Which information would the nurse provide to this patient?
1. "You will be taken to a special chamber where you can be isolated." 2. "You will be required to exercise on a treadmill for this testing." 3. "You can expect this test to take about 15 to 20 minutes." 4. "In order for results to be accurate, I will need to measure your height." 5. "We will not be able to do this test until you are off the mechanical ventilator."
A patient is being admitted for possible early-stage viral meningitis. The nurse would assess for which significant findings to help confirm the diagnosis?
1. A history of flulike symptoms resolving 5 days ago 2. Sluggish pupils bilaterally 3. Blood pressure of 100/62 4. A cervical lymph node palpable on physical examination
When documenting the fetus is at "zero station," the nurse knows this is where in relation to the pelvic structure?
A) Pelvic inlet B) Pelvic outlet C) Ischial spines D) Pelvic crest