The nurse, planning care for several clients, realizes that the one who would be at MOST RISK of experiencing sensory disturbances would be a:
a. 24-year-old client with a lower leg cast.
b. 44-year-old client who left her reading glasses at home.
c. normal 10-week-old infant.
d. 56-year-old client in intensive care after a heart attack.
ANS: D
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The final phase of the nursing process is evaluation, which focuses on:
a. recording the care that was implemented. b. medical and nursing goals for the welfare of the patient. c. long-term goals only. d. the patient responses to interventions and outcomes.
A patient with liver failure manifested by portal hypertension and ascites is hospitalized and waiting for a liver transplant. Which of the following orders should the nurse question?
a. Low-sodium diet b. Low-protein diet c. ABO typing d. Human leukocytic antigen tissue typing
A 40-year-old postoperative patient has a hemoglobin level of 8 g/dL and a SaO2 of 95 percent. Considering all aspects, the nurse concludes that the patient
1. has a potential risk of hypoxia. 2. is stable and at no risk. 3. has an elevated SaO2 for their age. 4. is adequately being oxygenated and at no risk for hypoxia.
A client in the critical care unit is scheduled to receive an enteral feed via gastrostomy tube. A nurse reviews the client's chart and realizes that the feeding should not be given for which reason?
A) The client is experiencing nausea. B) The client is being treated for peritonitis. C) The client is not alert or oriented. D) The client is unable to take liquids by mouth.