The nurse chooses to apply Montgomery ties to secure the dressing over a client's open abdominal wound that is being irrigated and packed every 8 hours. What nursing diagnosis does this intervention specifically support?
What will be an ideal response?
Risk for Impaired Skin Integrity
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A 52-year-old female patient is to begin calcitriol therapy. The nurse will advise the patient that an early adverse effect of the drug is often
A) bone pain. B) weight loss. C) polydipsia. D) hypertension.
An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him
a. from the right side. b. from the left side. c. from the center. d. from either side.
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava
" What is the best interpretation of these results by the nurse? a. The catheter is not positioned correctly and should be removed. b. The catheter position increases the risk of ventricular dysrhythmias. c. The distal tip of the catheter is in the appropriate position. d. The physician should be called to advance the catheter into the pulmonary artery.
The nurse explains to the postoperative ambulatory surgery client that his discharge will be delayed because of his
a. blood pressure of mm Hg. b. inability to void. c. mild incisional discomfort. d. pulse rate of 92 beats/min.