A patient is being admitted to the intensive care unit after being resuscitated in the emergency department. The patient is being mechanically ventilated. Which information provided by the transferring nurse would the nurse evaluate as increasing this patient's risk of developing ventilator-associated pneumonia (VAP)?
1. "The patient is intubated nasally."
2. "The patient arrested after having a myocardial infarction."
3. "The patient required placement of a nasogastric tube to relieve persistent gastric distention."
4. "The patient's home medications include a proton pump inhibitor."
5. "The patient has a history of chronic obstructive pulmonary disease (COPD)."
1, 3, 4, 5
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A teenager is being seen in the outpatient clinic after a fainting episode at home. The client's body mass index (BMI) is 16, and she reports no menses for the past 3 months. Which additional assessment finding would the nurse anticipate?
A) Absence of hair on arm and legs B) Tachycardia C) Clubbing of fingers and toes D) Complaint of temperature intolerance
A nurse is caring for a patient who is hospitalized for a mental disorder. The nurse is legally obligated to breach the patient's confidentiality if the patient states which of the following?
A) "I think that the federal government is spying on me." B) "I get really 'turned on' by your appearance." C) "That doctor I had today really made me angry." D) "When I get out of here, I'm going to kill my neighbor."
While caring for a patient in the critical care unit, the nurse realizes that the patient's care needs must be a balance between the patient's long-term prognosis and the family's expectations of recovery
Which of the AACN Synergy Model's characteristics does this situation describe? 1. Complexity 2. Predictability 3. Participation in care 4. Resource availability
A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient’s current serum potassium is 2.7 mg/dl. Which nursing diagnosis is most applicable?
a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss
b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia
c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia
d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia