A trauma patient is hemorrhaging from multiple gunshot wounds to the lower abdomen. The nurse provides care based on which priority nursing diagnosis (NDX)?
1. Ineffective Breathing related to shallow respirations
2. Fluid Volume Deficit related to effects of decreased renal perfusion
3. Impaired Ventilation related to airway obstruction
4. Ineffective Tissue Perfusion related to hypovolemia
4
Rationale 1: Pain from the wounds may cause splinting, which would affect breathing depth and rate, but this is not the priority NDX.
Rationale 2: The fluid volume deficit is not related to effects of decreased renal perfusion.
Rationale 3: There is no information to support airway obstruction as a related factor.
Rationale 4: When a patient is hemorrhaging, the tissues are not being perfused. Therefore, major organs such as the heart, brain, and lungs receive oxygenation, but other organs such as kidneys, intestines, and long muscles do not receive oxygenation and become ischemic.
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A nursing student is nearing graduation and is preparing to write the NCLEX-PN®. In preparation for the exam, the student has familiarized herself with computer adaptive testing (CAT). Which of the following statements about CAT is most accurate?
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a) Informed consent b) Authorization to disclose PHI c) Healthcare power of attorney d) None required
A nurse is giving a talk to a local community group on health promotion and illness prevention. The nurse explains the different levels of promotion. Which of the following does the nurse include when talking about primary promotion? Select all that apply
A) Immunization clinics B) Poison control information C) Screenings for blood pressure D) Recommending mammograms for women E) Teaching about a healthy diet
By allowing the ICU patient's family to visit as often as the patient's condition will allow, the nurse is considering which type of need within the patient and his family?
a. Trust b. Social support c. Environmental d. Dependence