You examine the urinary catheter and tubing for obstructions, and find none. What other
assessments do you need to gather?
What will be an ideal response?
Note intake and output record, daily weight, blood pressure trends, laboratory results; look for
absolute values and trends for creatinine, BUN, urinalysis (UA) findings, and urine osmolality. Quickly
review the chart to see what his urinary output has been running. Look at the physician orders for
urinary output parameters; if there are none, call the physician and report the urinary output.
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The term Nursing Process refers to:
a. a health-care approach focusing on patient compliance and trust. b. a problem-solving method for developing a plan of care. c. health-promotion approaches that focus on wellness outcomes. d. legal standards guiding nursing care.
An elderly patient with a history of congestive heart failure was just admitted for chest pain. The patient asks a nurse, "Why did my chest pain begin after I thought someone was trying to break into my house?" The best response by the nurse is:
1. "Response to fear increases the body's demand for oxygen, which can place additional stress on your damaged heart and cause chest pain." 2. "The parasympathetic system used all of your available adrenaline, leaving you so tired that you developed chest pain." 3. "Because the release of cortisol blocks the body's response to fear, you weren't allowed sufficient time to rest, which can cause chest pain." 4. "The decrease in oxygen use during the fight-or-flight response is most likely the reason that you developed chest pain."
When the patient asks what the purpose of goniometry is, the nurse replies that goniometry measures:
a. bone strength. b. muscle density. c. muscle strength. d. range of motion.
Pressure ulcers are more likely to occur
A) over bony prominences. B) when patients eat a well-balanced diet. C) on ambulatory patients. D) none of the above