The nurse admits a patient who is scheduled for surgery tomorrow morning
The nursing admission assessment indicates that the patient is mildly anxious about the procedure, does not drink alcohol or smoke, is married with two children, and is allergic to kiwi, avocados, and penicillin. The nurse identifies the priority nursing diagnosis for this patient as:
a. Fear
b. Anxiety
c. Risk for Latex Allergy Response
d. Ineffective Airway Clearance
C
Risk for Latex Allergy Response is appropriate for patients who are allergic to bananas, avocados, kiwi, chestnuts, or poinsettia plants. This patient has two of these allergies, so this is a priority diagnosis. The patient is only mildly anxious, and there are no defining characteristics of Fear; therefore Fear would not be an appropriate diagnosis. Although the patient does have mild Anxiety, this is not the priority diagnosis for this patient. There is no indication that this patient will have, or currently has, Ineffective Airway Clearance.
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The nurse assesses a patient who has been given phentolamine [OraVerse] to treat pheochromo-cytoma. The nurse notes a blood pressure of 76/52 mm Hg and a heart rate of 90 beats per minute. Which action by the nurse is correct?
a. Contact the provider to request an order for epinephrine. b. Continue to monitor the patient's vital signs and notify the provider if the heart rate increases. c. Notify the provider and request an order for a beta blocker. d. Notify the provider and request an order for norepinephrine.
The nurse is caring for a client who recently began taking prescribed blood pressure medicine. Which teaching will be most important to this client in the prevention of falls?
A. Wear slipper or non-skid socks when walking. B. Make sure that the lighting is good when you get out of bed. C. Use the handrails next to the toilet when getting on and off the toilet. D. Sit on the side of the bed for at least a minute before getting out of bed.
Duties of the home health assistant include
A. personal care and treatments. B. managing the budget. C. housekeeping and yard work. D. paying the bills.
A female patient who takes lorazepam [Ativan] for anxiety tells the nurse that she plans to become pregnant. What is the best instruction for the nurse to give the patient?
A. "Eat a well-balanced diet that includes milk." B. "Discuss tapering the drug with the provider before conception." C. "Stop taking the drug and form another plan to manage anxiety." D. "Visit an obstetrician to determine the correct dose of lorazepam during pregnancy."