A patient with acute congestive heart failure has jugular vein distention, crackles bilaterally, and dyspnea. Which nursing diagnosis should have the highest priority?
a. Activity intolerance
b. Excess fluid volume
c. Anxiety
d. Ineffective coping
B
Fluid volume excess increases the workload of the heart and interferes with breathing.
You might also like to view...
To which diet should a patient with Cushing syndrome adhere?
a. Less sodium b. More calories c. Less potassium d. More carbohydrates
A patient who has a permanent hearing impairment asks the nurse what communication aids are available. What would the nurse tell the patient? (Mark all that apply.)
A) Speech reading B) Hearing Aids C) Oral training D) Hearing guide dogs E) Lip training
The mother of a 10-month-old infant asks the nurse about beginning to wean her child from his bottle. Which statement by the mother suggests that the child is not ready to be weaned?
a. "My son is frequently throwing his bottle down." b. "The baby takes a few ounces of formula from the bottle." c. "He is constantly chewing on the nipple. It concerns me." d. "He consistently is sucking."
Oxygen is humidified to:
a. Prevent irritation from the administration device b. Keep the airway moist c. Keep the airway dry d. Prevent secretions