A problem with assessment data may be that
a. the data are comprehensive
b. the client may be unwilling to share data
c. complete validation is needed
d. the nursing diagnosis is clear
B
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A patient presents at the clinic complaining of shortness of breath, fatigue, and difficulty performing activities of daily living (ADLs). The nurse notes the bluish color around the patient's mouth and fingernail beds
What would the nurse expect the patient has? A) A dysrhythmia B) Hypotension C) Heart failure D) Hypertension
A client is admitted with a core body temperature of 93 °F. Which action by the nurse is appropriate for this client?
A) Apply warm soaks to the extremities. B) Use a hyperthermia blanket. C) Provide warm fluids. D) Use warm blankets.
The type 1 diabetic patient has an insulin order for NPH insulin, 35 U, to be given at 7 AM. The patient is also NPO for laboratory work that will not be drawn until 10 AM. The nurse should:
1. give the insulin as ordered. 2. give the insulin with a small snack. 3. inform the charge nurse. 4. hold the insulin until after the blood draw.
The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period?
A) Anxiety related to new feeding method used postoperatively B) Ineffective tissue perfusion related to pressure on heart chambers C) Excess fluid volume related to increased fluid intake prescribed postoperatively D) Risk for infection of incision line, related to disruption of skin barrier during surgery