The nurse is caring for a client admitted with a diagnosis of appendicitis. The client has a history of kidney transplant, and takes immune-suppressing medications to prevent organ rejection
Which of the following nursing diagnoses would be most appropriate for this client postoperatively? 1. Infection, risk for, related to nutritional deficit
2. Infection, risk for, related to overhydration
3. Infection, risk for, related to immunosuppression
4. Infection, risk for, related to postoperative wound
3
Rationale 1: This client is at risk due to immunosuppression and an inadequate immune response to pathogens. While the postoperative wound might be the pathogens' easiest entry point, infection could occur because of the client's IV site, airway, or any other entry point, so the immune suppression is the primary concern, creating a susceptible host. Nutritional and hydration status are unknown.
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The nurse understands that an indication for the use of asparaginase (Elspar) is:
1. Lung cancer 2. Breast cancer 3. Metastatic prostate cancer 4. Acute lymphocytic leukemia
A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life
The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? a. "Let's call 911 because this freshman student is suicidal." b. "Give the freshman student this list of university and community resources." c. "I recommend that you help the freshman student start packing bags to go home." d. "You must make an appointment for the freshman student to obtain medications."
Which would be the most effective approach for a nurse to take when assessing the self-care needs and activities of daily living (ADLs) for an older adult?
a. Observe the level of grooming and dress that the patient demonstrates on a daily basis. b. Interview the patient with a focus on how daily toileting and bathing are typically achieved. c. Offer to provide the patient with the typical activities involved with bathing and grooming. d. Interact with the patient to determine his or her ability to bathe, toilet, eat, and dress independently.
When making an occupied bed,
A. cover the patient with a bath blanket when removing the top sheet. B. begin making the bed at the foot and work your way to the head. C. lift the patient gently to slide the linen under him. D. keep the bed in the low position with the rails down.