A nurse prepares the plan of care for a patient with nasogastric enteral feeding. Which nursing diagnosis would have the highest priority?
1. Risk for aspiration
2. Risk for injury
3. Risk for fluid volume imbalance
4. Risk for nausea
Correct Answer: 1
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A client is standing in the hallway on the phone arguing with the caller. As the client becomes increasing loud and argumentative, an appropriate action for the nurse to take would be to:
1. Move the other clients away from the area providing the client privacy to continue the conversation. 2. Stand next to the client and say in a calm, firm voice, "If you cannot lower your voice, you will lose your phone privileges indefinitely." 3. Walk up to the client and softly say, "This conversation appears to be getting you upset, tell this person that you will talk later and come sit with me to discuss what is bothering you." 4. Do nothing. The client does not pose any danger as the person the client is angry with is not physically present.
A public health nurse is giving an informational presentation on HIV/AIDS at a nearby college. How would the nurse best define AIDS?
A) Acquired immunodeficiency syndrome is an infection by the human immunodeficiency virus. B) Acquired immunodeficiency syndrome is a fatal infection that profoundly weakens the immune system. C) Acquired immunodeficiency syndrome is a sexually transmitted disease. D) Acquired immunodeficiency syndrome is an infectious disease transmitted in blood and body fluids.
A patient with ovarian cancer is admitted to the hospital for surgery. You are completing a health history on the patient. What clinical manifestations would you expect to assess?
A) Fish-like odor of the vagina B) Increased abdominal girth C) Fever and chills D) Lower abdominal pelvic pain
The nurse administered ticarcillin (Ticar) to a patient with the morning medications. Later, when assessing the patient, the nurse notes a light red rash with pruritus. The prescriber is notified and orders a desensitization of the medication
The nurse correctly explains to the patient which of the following procedures? a. Desensitization involves a small initial dose, which is followed by increasing doses every 60 minutes. b. Desensitization involves infusing the same dose of medication but in a more di-lute solution. c. Desensitization involves administration of a pretreatment of Tylenol and diphen-hydramine (Benadryl). d. Desensitization involves administration of the medication continuously rather than every 8 hours.