The nurse caring for a patient with an open fracture of the radius is developing a care plan for the patient. The nurse will assign priority to which of the following nursing diagnoses?
A) Risk for infection
B) Risk for activity intolerance
C) Risk for imbalanced nutrition, less than body requirements
D) Risk for powerlessness
Ans: A
Feedback: All of these nursing diagnoses may be pertinent to the care of a patient with an open fracture of the radius, but the highest priority diagnosis is risk for infection of osteomyelitis and tetanus. The objectives of management are to prevent infection of the wound, soft tissue, and bone and to promote healing. Another priority diagnosis for a patient with an open fracture would be risk for peripheral neurovascular dysfunction.
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1. Those who deliver the nursing care make the most educated decisions for a particular unit. 2. Clinical decision making is best made by nursing leaders for all units within that particular hospital. 3. Those nurses working in particular service area are best suited to make decisions for the clients in that area. 4. Clinical decision making is best made by the clients who are served by a particular unit.
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1. Assess the client for skin tenting. 2. Obtain a reading on the pulse oximeter. 3. Check the client's temperature. 4. Evaluate for edema.
Which precaution is most important for the nurse to teach a patient who is prescribed any antidepressant drug?
a. "Avoid drinking grapefruit juice while taking this drug." b. "Avoid drinking alcoholic beverages while taking this drug." c. "Be sure to wear sunscreen and a hat when going outdoors." d. "Drink at least 3 liters of fluid every day while taking this drug."
A person's hair is matted and tangled. What should you do?
a. Braid the person's hair. b. Cut the person's hair. c. Tell the nurse. d. Shampoo the person's hair.