A patient with cirrhosis is experiencing hypertension, edema, and shortness of breath. What should the nurse identify as the patient's priority problem?
1. insufficient fluid level
2. problem with tissue perfusion
3. too much bodily fluid
4. problem with integumentary status
Correct Answer: 3
The patient with shortness of breath, edema, and hypertension is experiencing an excessive amount of fluid. Hypotension and dry mucous membranes are associated with a fluid volume deficit. There is no evidence that the patient is having problems with tissue perfusion. Edema can cause an alteration in skin integrity, but there is no evidence of such problems in this patient.
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A) Irritable voiding symptoms and depression B) Urgency and bacteria in the urine C) Normal bladder capacity and frustration D) Frequency and bacteria in the urine
The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid?
A. Crossing legs at the ankle B. Using an elevated toilet seat C. Placing a pillow between the legs D. Keeping the legs abducted from the midline
When teaching an individual for whom English is a second language, it is advisable to: a. have the individual's relatives listen to theinformation
b. have an interpreter present. c. have printed information in the individual'slanguage. d. b and c.
The fat-soluble vitamins are ________.
A. vitamins A, B, D, and K B. vitamins A, D, E, and K C. vitamins A, B, C, and D D. vitamins A, B, D, and E