Your patient is a 72-year-old man with diabetes mellitus requiring daily monitoring of his blood glucose level. Prioritize the following nursing diagnoses for this patient:
a. Imbalanced nutrition, greater than body requirements
b. Risk for infection related to unstable blood sugar
c. Impaired skin integrity related to second-degree right malleolar decubitus
d. Disturbed body image related to obesity
1. b, c, d, a
2. a, d, b, c
3. d, b, c, a
4. c, b, a, d
ANS: 4
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After a ureterolithotomy, a female patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care?
a. Provide teaching about home care for both catheters. b. Apply continuous steady tension to the ureteral catheter. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops.
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?
A) Pallor B) Purple-blue C) Irritation and bleeding D) Dark red and moist
A patient who recently returned from surgery is experiencing nausea. Which statement best explains why this patient would benefit from IV medication administration?
1. The IV is already in place following the surgery. 2. IV medication administration should be avoided in patients with nausea. 3. Medications are more effective when given IV. 4. IV medications bypass the need for GI absorption.
A nurse practitioner uses cognitive therapy with depressed clients. The nurse asks clients to keep a daily record of dysfunctional thoughts
Which of the following are appropriate nursing replies to a client questioning the purpose of this exercise? Select all that apply. A. "The purpose of this exercise is to identify automatic thoughts." B. "The purpose of this exercise is to identify rational alternatives." C. "The purpose of this exercise is to modify cognitive errors." D. "The purpose of this exercise is to eliminate irrational beliefs." E. "The purpose of this exercise is to monitor thoughts related to self-esteem."