The nurse observes a patient doing all these activities after having a hip-replacement surgery. Which patient action requires that the nurse intervene immediately?
a. The patient sits straight up on the edge of the bed.
b. The patient leans over to pull shoes and socks on.
c. The patient bends over the sink while brushing the teeth.
d. The patient uses crutches with a swing-to gait.
Answer: b. The patient leans over to pull shoes and socks on.
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The nurse is caring for a client admitted with pneumonia. Which assessment findings would help determine the type of pneumonia the client is experiencing?
1. The client's complaint of shortness of breath 2. Productive cough with large amounts of rust-colored sputum 3. The client's complaint of chest pain 4. A temperature of 38.3 °C (101 °F)
A client with chronic and progressive multiple sclerosis is ordered to receive cyclophosphamide (Cytoxan) to decrease symptoms. Based on this class of drug, which nursing diagnosis is a priority during this treatment?
a. Risk for injury owing to seizure activity b. Risk for infection owing to immunosuppression c. Risk for constipation owing to neurotoxicity d. Risk for deficient fluid volume owing to diuresis
A child with cystic fibrosis has been having bouts of constipation and diarrhea. What should the nurse teach the caregivers to adjust in the child's diet?
A) Iodized salt B) Saturated fat C) Pancreatic enzymes D) Calories from protein
When assessing skin turgor in a client, the nurse observes that the skin remains elevated
for around two seconds. The nurse should document the skin tenting as _____ A) +1 B) +2 C) +3 D) +4