The nurse is caring for a client with a DVT (deep vein thrombosis) receiving heparin intravenously (IV). Which is the priority outcome for the client?
A. The client will comply with dietary restrictions.
B. The client will keep the right leg elevated on two pillows.
C. The client will not disturb the intravenous infusion.
D. The client will not experience bleeding.
Answer: D
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The significance of developing organized plans of care for patients cannot be stressed enough. In the planning phase, the nurse must take seriously the responsibility of: (Select all that apply.)
a. prioritizing patient needs. b. developing mutually agreed-on goals. c. determining outcome criteria. d. identifying interventions. e. implementation of the patient's plan of care.
A nurse is implementing community-based nursing care. Which of the following nursing inter-ventions is the nurse most likely to complete?
a. Assessing the health needs of a defined community b. Providing care to families in a community c. Promoting the health of an entire commu-nity d. Investigating environmental health prob-lems in a community
Which nursing intervention ensures an accurate cardiac output reading for a patient?
1. Administer the injectate within 4 seconds. 2. Use 5 cc of iced saline as the injectate. 3. Ensure that there is a difference of 10°C between the injectate temperature and the patient's body temperature. 4. Inject the fluid into the pulmonary artery distal port.
A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?
A) White blood count of 10,000 mm3. B) Serum glucose of 115 mg/dl. C) Purulent sputum. D) Excessive hunger.