The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Imbalanced nutrition r/t poor appetite and increased metabolic needs
c. Ineffective airway clearance r/t thick secretions in trachea and bronchi
d. Knowledge deficit r/t use of nebulizer and inhaled bronchodilators
ANS: C
Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patient's airway is kept patent.
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One of the nurse's older adult patients is abusing laxatives. Which would be an appropriate intervention for this patient to help reduce this chronic laxative use and dependency?
a. Advise the patient to take a laxative once weekly. b. Stop the patient from taking any laxatives. c. Have the patient take an enema instead of a laxative. d. Have the patient drink 6 to 8 glasses of water each day.
Which of the statements is true, relative to error? (Select all that apply.)
a. True score plus error score equals observed score. b. Random error of measurement increases the mean. c. The mean of the true measurements is equal to the mean of the observed measurements when there is no systematic error. d. No measurement of anything is ever correct. e. Measurement error always exists, if a straightforward measurement like counting is made often enough and by enough people.
When prescribing phosphodiesterase type 5 (PDE-5) inhibitors such as sildenafil (Viagra) patients should be screened for use of:
1. Statins 2. Nitrates 3. Insulin 4. Opioids
The nurse preparing to infuse vancomycin will monitor the client for:
Standard Text: Select all that apply. 1. loss of hearing and balance. 2. reddening upper body with dizziness. 3. confusion or hallucinations. 4. abnormal liver function. 5. fever and chills.