The nurse is developing a plan of care for a 7-year-old boy with diabetes insipidus. Which of the following would the nurse most likely identify as the priority nursing diagnosis?
A) Deficient fluid volume related to dehydration
B) Excess fluid volume related to edema
C) Deficient knowledge related to fluid intake regimen
D) Imbalanced nutrition, more than body requirements related to excess weight
A
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A nurse working in the ICU receives orders for dopamine, which is an intravenous vasoactive drug. The priority assessment and interventions specific to the administration of vasoactive medications are:
A) Frequent vitals, monitoring the central-line site, and providing accurate drug titration B) Reviewing medications, performing a focused cardiovascular assessment, and providing patient education C) Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema. D) Routine vitals, monitoring the peripheral IV site, and providing early discharge instructions.
The patient has just returned from having an arteriovenous fistula placed. The patient asks, "When will they be able to use this and take this other catheter out?" The nurse should reply,
a. "It can be used immediately so the catheter can come out anytime." b. "It will take 2 to 4 weeks to heal before it can be used." c. "The fistula will be usable in about 4 to 6 weeks." d. "The fistula was made using graft material so it depends on the manufacturer."
While caring for a labor client, you notice during a vaginal exam that the baby's head has rotated internally. What would you expect the next set of cardinal movements for a baby in a vertex presentation to be?
1. Flexion, extension, restitution, external rotation, expulsion 2. Expulsion, external rotation, restitution 3. Restitution, flexion, external rotation, expulsion 4. Extension, restitution, external rotation, expulsion
A client has received thrombolytic therapy after having a myocardial infarction. Which clinical manifestation would indicate to the nurse that reperfusion has been successful?
A. ST-segment depression B. Cessation of diaphoresis C. Sudden onset of pleuritic chest pain D. The onset of ventricular dysrhythmias