An older adult client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate?
A) Ineffective Airway Clearance
B) Impaired Tissue Perfusion
C) Ineffective Breathing Pattern
D) Activity Intolerance
Answer: C
The client is experiencing an increased respiratory rate and is wheezing, which is an ineffective breathing pattern. Not enough information is provided to determine whether the client has ineffective airway clearance, activity intolerance, or impaired tissue perfusion.
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A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best?
a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.
A hospital client is receiving intravenous infusion of heparin for treatment of a pulmonary embolus. Which of the following phenomena is most likely to occur, resulting in the drug's therapeutic effect?
A) Inhibition of vitamin K synthesis in the liver B) Suppression of fibrin formation C) Deactivation of the intrinsic clotting pathway D) Inhibition of ADP-induced platelet aggregation
Which teaching point is appropriate for a nurse to include when teaching a patient who has undergone a liver transplant?
1. "Your immunosuppressive medications may cause weight loss.". 2. "Reduce scheduled tacrolimus to every other day if nausea occurs.". 3. "Take acetaminophen (Tylenol) if fever develops.". 4. "Report sore throats to your health care provider.".
The RN saw a gentleman from an Arabic country asking the doctor how his wife was doing. As the physician responded to the question, the physician backed away. The man again moved up close to the physician to ask another question, which the doctor answered
What might the nurse conclude? A. Both were trying to arrange the space between them to be comfortable. B. The gentleman had such bad breath that no one could stand to be close to him, and the nurse would have to talk to him about dental hygiene. C. The physician was a bigot who could not stand to be near an Arab. D. These things happen; there is no particular meaning to this event.