A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5). Show
10. B, C, D The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase. 11. A, B Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it. 12. A, B, C, D Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful. 13. B, D, E Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache, visual disturbances such as diplopia, blurred vision, yellow-green halos, photophobia, drowsiness, fatigue, and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. 14: B, C, D, G 15. A, C, D 16. B, C, E, F 17. B, D, E 18. B, A, E, C, D 19. A, D, E 20. D, F, G, H 21. A, B, C, D 22. C, A, D, B 23. A, C, D, E, B 24. A, B, E B. Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is absorbed. The amount of pain should be measured and documented with either a 1-10 scale or the Wong's FACES for younger children. C. A special diet is not indicated after this surgery. D. After a laparoscopic appendectomy, there is little drainage and no dressings. E. Auscultating for bowel sounds and documenting their presence or absence evaluate the child's adaptation to the intestinal trauma caused by the surgery. 25. A,B,D The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night is not indicative of impaired respiratory health. Which laboratory result is important to monitor in the patient receiving furosemide?Careful monitoring of the patient's clinical condition, daily weight, fluids intake, urine output, electrolytes, i.e., potassium and magnesium, kidney function monitoring with serum creatinine and serum blood urea nitrogen level is vital to monitor the response of furosemide.
What lab value should the nurse expect to monitor for a patient receiving furosemide?Lab Test Considerations:
Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonly ↓ serum potassium. May cause ↓ serum sodium, calcium, and magnesium concentrations.
How does furosemide affect potassium?Furosemide is a diuretic that removes extra water and certain electrolytes from the body by increasing the amount of urine produced. In doing so, it causes potassium loss. Potassium chloride is a mineral supplement added to prevent low levels of potassium in the blood.
Which adverse effect would a nurse monitor for when caring for a client receiving furosemide to relieve edema?Monitor the patient closely for hypokalemia if furosemide is used concomitantly with digoxin. Hypokalemia may increase the risk of digoxin toxicity. Adverse effects include dehydration, hypotension, and electrolyte imbalances such as hypokalemia.
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