The nurse preparing to prioritize identified nursing diagnoses for a client. In which step of the nursing process does this activity occur?
a. Assessment c. Outcome identification and planning
b. Diagnosis d. Evaluation
ANS: C
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A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should
a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.
The nurse has given the client with atrial fibrillation instructions to take one 1 aspirin daily. The client says to the nurse, "Why do I need to take this? I don't get any pain with my heart rhythm."Which response by the nurse is the most appropriate?
1. "This will keep you from experiencing chest pain." 2. "This will most likely keep you from ever having a heart attack." 3. "This will prevent any inflammation from occurring on the walls of your heart." 4. "This will help prevent clot formation in your heart as a result of your heart's rhythm."
A victim of a motor vehicle crash has an acute cervical spinal cord injury. Which problem should the nurse identify as the priority for this patient?
A. Problems with the airway B. Altered blood flow C. Changes in mobility D. Fluid maintenance