An older adult with gastroenteritis is disoriented and weak and has the following laboratory test results: Hct 56% (normal 40% to 51%) BUN 32 mg/dL (normal 6 mg/dL to 20 mg/dL) Which nursing diagnosis should the nurse select for this patient?
a. Risk for injury
b. Excess fluid volume
c. Deficient fluid volume
d. Impaired skin integrity
ANS: C
C. Elevated blood urea nitrogen (BUN) and hematocrit (Hct) show concentration due to Deficient fluid volume. B. Excess fluid volume would be associated with low BUN and Hct. A. D. Impaired skin integrity and Risk for injury are possible, but they are not indicated by the data provided.
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A. Provide the best care, whatever the cost. B. Deliver quality care at lower cost. C. Deliver care to only the insured. D. Encourage alternative treatment.
The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level?
a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"
How can the nursing staff encourage sleep in long-term care facility residents? (Select all that apply.)
a. Using the minimum light necessary when making rounds b. Making necessary sleep interruptions at the same time every night c. Keeping conversational noise at the nursing station to a minimum d. Answering call lights promptly e. Providing heavy blankets for warmth
When assessing zone of coagulation of a third-degree burn injury, the nurse would be alert for:
1. The presence of pain 2. Brisk capillary refill 3. Surface of the wound that is dry and firm 4. A bright red wound color