A patient is being admitted to the intensive care unit with multiple trauma, and the nurse is reviewing and implementing the admission orders, which include the insertion of an indwelling urinary catheter
Which nursing diagnosis is a consequence of this intervention?
A) Risk for Excess Fluid Volume
B) Risk for Infection
C) Risk for Acute Urinary Retention
D) Risk for Dysfunction Gastrointestinal Motility
B
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A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.)
a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune-suppressing drugs?" e. "Do you drink grapefruit juice or orange juice daily?"
The nurse is assessing a client's breath sounds. Which assessment finding has been correctly linked to the nurse's primary intervention?
a. Hollow sounds heard over trachea; in-crease oxygen flow rate. b. Crackles heard in bases; have the client cough forcefully. c. Wheezes heard in central areas; administer inhaled bronchodilator. d. Vesicular sounds heard over the periphery; have the client breathe deeply.
Select the action by the nurse that has the highest priority in the care of several clients who are receiving postoperative pain management by epidural analgesia on the surgical unit
a. Change the IV tubing with each bag of medication. b. Keep the head of the bed elevated 30 de-grees to prevent hypotension. c. Monitor peripheral pulses every 2 hours. d. Assess for movement and sensation of the feet and legs each shift.
All of the following statements are true about families except:
1. All families are social systems. 2. Commitment and attachment exist among family members. 3. Family members may or may not be related and may or may not live together. 4. Families consist of a couple and children (although the children may be grown). 5. Families provide protection, nourishment, and socialization for members.