For a patient who has chronic obstructive pulmonary disease with an excess of secretions in the bronchioles, which nursing diagnosis is most appropriate?
A) ineffective airway clearance
B) altered respiratory pattern
C) high risk of asphyxia
D) difficulty maintaining spontaneous ventilation
A) ineffective airway clearance
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The nurse is interviewing a patient. What behavior observed during the interview could indicate hearing loss?
a. Patient cups the ear during interview. b. Patient leans away from the nurse during interview. c. Patient answers questions appropriately. d. Patient complains of people talking loudly.
The nurse instructs the spouse of a client who is experiencing dysphagia. which statement indicates that teaching about strategies to help with dysphagia were effective?
a. "I should encourage liquids as often as possible." b. "Foods like gelatin and pasta will be easy to swallow." c. "We should have a casual conversation during meals." d. "It is necessary to sit in a 90-degree angle to the lap when eating."
While admitting a client to the emergency room, the nurse observes the cardiac monitor and identifies the following rhythm: one inverted P wave for every QRS complex and a regular heart rate of 46 beats per minute
The nurse interprets this rhythm as: 1. Junctional escape rhythm. 2. Normal sinus rhythm. 3. Mobitz II heart block. 4. Complete heart block.
The nurse administers sulfamethoxazole and trimethoprim (Bactrim) for a desirable client response derived from the combination of agents. Which type of medication effect does the nurse anticipate?
1. Tolerance 2. Synergistic 3. Dependence 4. Subtherapeutic