The nurse planning the care for a client diagnosed with a postpartum deep vein thrombosis would identify which of the following nursing diagnoses as being a priority for the client?
1. Excess Fluid Volume related to tissue edema
2. Disturbed Sleep Pattern related to tissue hypoxia
3. Risk for Infection related to obstructed venous return
4. Ineffective Tissue Perfusion related to obstructed venous return
4. Ineffective Tissue Perfusion related to obstructed venous return
Rationale:
Ineffective tissue perfusion related to obstructed venous return is the correct diagnosis because it identifies the underlying cause. Excess fluid volume related to tissue edema and disturbed sleep pattern related to tissue hypoxia are incorrect because they do not identify the underlying cause. Risk for infection related to obstructed venous return might be a diagnosis if complications of infection are present, but no indication for that is provided.
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The nurse finds a positive Blumberg's sign in a client with abdominal pain. Which action does the nurse plan?
a. Have the client be NPO in preparation for surgery. b. Document this normal finding in the client's record. c. Immediately auscultate the client's abdo-men for bowel sounds. d. Repeat the maneuver with the client in a supine position, with the knees flexed.
A patient, recovering from a kidney transplant, has a temperature of 38 degrees C. Which of the following should the nurse do?
1. Report the temperature so a thorough assessment of the source can be discovered and treated. 2. Document the temperature and begin trending over the next 24 hours. 3. Provide antipyretic medication as prescribed. 4. Increase fluids and encourage ambulation.
A client with a disability, who still requires restorative care in order to return to a prior level of functioning, is being discharged from the medical unit in the hospital. To which type of facility should this client be referred?
a. An assisted-living facility b. An adult day care centre c. An extended care facility d. A home health care agency
A staff nurse accidentally provided a client with an incorrect stock medication, however did not report the occurrence to anyone. What behavior is this staff nurse demonstrating?
1. At-risk 2. Human error 3. Recklessness 4. Fear of punishment