The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client complains of unpleasant tastes and odors as well. Which of the following measures should be included in the nurse's care plan?
A) Ensure adequate hydration with additional water.
B) Provide frequent mouth care.
C) Keep the feeding formula refrigerated.
D) Flush the tube with water before adding the feedings.
B
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The nurse is caring for a patient experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
A) Pulmonary embolism B) Heart failure C) Cardiac tamponade D) Tension pneumothorax
Which of the following is not included in the nine human response patterns of the NANDA nursing diagnosis taxonomy?
a. valuing c. knowing b. feeling d. thinking
You note all of the following changes in the last week in a 72-year-old nursing home patient taking nortriptyline (Pamelor) for chronic pain. For which problem do you immediately notify the prescriber?
a. Heart rate decreased from 80 to 72 beats/min. b. Respiratory rate decreased from 20 to 16 breaths/min. c. Weight increased from 128 to 137 lb. d. Morning blood glucose increased from 86 to 94 mg/dL.
The nurse is caring for clients in a hospice program. Which of the following is a recommended nursing care guideline when caring for this population?
A) Focus on problems. B) Try to predict the exact time of death. C) Maintain a sense of humor. D) Do not allow the client to be alone.