When meeting with a client and family, the home health nurse says, "We have discussed your health problems and limitations. Now tell me what level of health and function you hope to achieve."
In which of the following phases of the nursing process is the nurse engaging?
a. Assessment
b. Diagnosis
c. Outcome identification
d. Planning
ANS: C
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A patient asks a nurse what an AIDS-related opportunistic infection is. Which should be the nurse's reply?
a. "This infection is a first-generation metabolic infection." b. "This infection is a toxic effect of the virus." c. "This infection is from damage to the body's immune system." d. "This infection is from an enlarged gallbladder."
If a client is to receive an entire 250-mL bag of saline over the next 4 hours and the drop rate of the IV tubing chamber is 15 drops/mL, at what drop rate per minute will the nurse set this IV? ____________ drops/min
Fill in the blank(s) with correct word
It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action?
a. Monitor the client's oxygenation. b. Teach the client about potential side ef-fects. c. Monitor the IV insertion site. d. Monitor for bleeding.
During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?
1. abnormal hypoglossal nerve response 2. first cranial nerve (CN I) damage 3. sluggish oculomotor response 4. absence of the Homans sign