The nurse is developing a teaching plan for an elderly patient who will begin taking an antihypertensive drug that causes dizziness and orthostatic hypotension. Which nursing diagnosis is appropriate for this patient?
a. Deficient knowledge related to drug side effects
b. Ineffective health maintenance related to age
c. Readiness for enhanced knowledge related to medication side effects
d. Risk for injury related to side effects of the medication
ANS: D
This patient has an increased risk for injury because of drug side effects, so this is an appropriate nursing diagnosis.
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A patient is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals an oral temperature of 100.5ºF and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action?
A) Apply supplementary oxygen by nasal cannula. B) Administer bronchodilators by nebulizer. C) Liaise with the respiratory therapist and consider high-flow oxygen. D) Inform the primary care provider that the patient may have an infection.
The nurse assesses that her patient's intravenous solution has infiltrated into the tissues. What action should1) Aspirate, then inject 0.5 mL normal saline. 2) Restart the IV line in a different vein. 3) Stop the infusion immediately. 4) she take first?
1) Aspirate, then inject 0.5 mL normal saline. 2) Restart the IV line in a different vein. 3) Stop the infusion immediately. 4) Notify the primary care provider.
The nurse clarifies to a new client in a rehabilitation center that "rehabilitation" means that the client will:
1. return to his previous level of functioning. 2. be counseled into a new career. 3. develop better coping skills to accept his disability. 4. attain the greatest degree of independence possible.
How does a nurse assess for fluid in a patient's abdomen?
a. Placing the nondominant hand (pleximeter) over the area to be percussed, and striking the index finger of the pleximeter with the pad of the middle finger of the dominant hand b. Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexor c. Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed, and striking that finger with the tip of the middle finger of the dominant hand d. Using direct percussion by placing one hand over the abdomen and striking lightly with the other hand