The nurse is contributing to a patient's plan of care who is recovering from heart transplant surgery. The patient is shivering and has weak peripheral pulses, mottled skin on the feet, and excessive chest tube drainage
Which nursing diagnosis would be a priority for the nurse to recommend?
a. Pain related to sternotomy and incisions
b. Decreased Cardiac Output due to hypovolemia
c. Risk for Infection due to inadequate primary defenses from surgical wound and immunosuppression
d. Risk for Impaired Skin/Tissue Integrity due to incision
ANS: B
The patient is losing fluid volume through the chest tube and is at risk for hypovolemia and decreased cardiac output.
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The nurse is assisting with medication teaching for a patient who is prescribed lithium carbonate (Eskalith) for bipolar disorder. Which instruction by the nurse is most important?
a. Teach the patient side effects to report, such as nausea or weight gain. b. Instruct the patient to discontinue other antidepressant agents. c. Explain to the patient and significant other the importance of regular blood tests. d. Teach the patient that the lithium will help stabilize mood swings.
A nurse administering a tube feeding for a client on a ventilator should be sure to place the client in a semi-recumbent position to prevent:
1. Overfeeding. 2. GERD. 3. Early satiety. 4. Aspiration.
There are several risk factors for substance abuse and addiction in individual people and populations. Using your knowledge of evidence-based practice in the nursing care of populations most at risk for substance abuse disease, substance use disorders are
associated with high comorbidity for which type of illness? A) COPD B) Diabetes C) HIV D) Major mental
The focus of the middle adulthood stage of development is
a. Developing close relationships with others b. Establishing personal identity c. Contributing to the next generation d. Developing a citizenship role