A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time?
1) Risk for Infection related to subcutaneous injuries
2) Risk for Impaired Skin Integrity related to immobility
3) Impaired Tissue Integrity related to ventilator dependency
4) Impaired Skin Integrity related to ventilator dependency
ANS: 2
You might also like to view...
A nurse is performing a musculoskeletal assessment of a patient with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of which of the following?
A) Fasciculations B) Clonus C) Effusion D) Crepitus
What interventions are required when Mrs James is admitted to the DSU for her surgery? Explain your answer
What will be an ideal response?
What is the mechanism of action for metoclopramide (Reglan), which is commonly prescribed for nausea and vomiting?
A. Contracts the muscles in the upper intestine, resulting in faster emptying of the stomach into the small bowel B. Produces a thick, gel-like substance that coats the stomach C. Suppresses the volume and acidity of parietal cell secretions D. Inhibits gastric acid secretion and stimulates to production of protective mucus
The nurse is caring for a postoperative patient and is evaluating the patient's intake and output as a measure to prevent AKI. The patient weighs 60 kilograms and has produced 180 mL of urine in the past 4 hours. What should the nurse do?
a. Perform other assessments related to fluid status and record the output. b. Call the health care provider and obtain an order for a fluid bolus. c. Encourage the patient to drink more fluid, so that the output is increased. d. Compare the patient's weight to baseline to determine fluid retention.