Amelia

ADPIE is the step by step clinical layout of the nursing process, it consists of? - Assessment, Diagnosis, Planning Interventions, Implementation, and Evaluating Outcomes. What is the purpose of a nursing assessment? - To collect data relevant to delivering nursing care. How is assessment relevant to the rest of the nursing process? - It is the foundation for the remainder of the process, it provides data needed to identify actual or potential health problems. What are the four types ...

During which of the five steps in the nursing process does the nurse determine whether outcomes of care are achieved? A. Implementation B. Evaluation C. Planning D. Analysis - B. Evaluation When considering the nursing process, the word "observe" is to "assess" as the word "explore" is to which of the following words? A. Plan B. Analyze C. Evaluate D. Implement - B. Analyze Which statement is related to the concept that is central to the nursing process? A. It is dynamic rat...

A patient tells the nurse, "I have had this dull ache in my side now for 4 days; it really hurts when I bend over." The nurse responds, "All right, go on." The nurse's response is an example of: A. inference. B. a cue. C. back-channeling. D. open-ended question. - C Back-channeling gives positive comments such as "all right," "go on," or "uh-huh" to the speaker, thus indicating that you heard what the patient is saying and are interested in hearing the full story. The nu...

The nurse is performing a shift assessment on a patient and is collecting objective and subjective data. The nurse recognizes which of the following as objective data? 1) Patient complains of a headache. 2) Patient holds her head in her hands. 3) Patient complains of feeling flushed. 4) Patient reports anxiety about hospitalization. - 2) Patient holds her head in her hands. The nurse is caring for a patient who had a coronary artery bypass graft. The nurse helps the patient to ambulate ...

1. A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? A) Bathe daily and keep the perineal region clean. B) Avoid voiding immediately after sexual intercourse. C) Drink liberal amounts of fluids. D) Void at least every 6 to 8 hours. - Ans: C Feedback: The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to increase urine production and flow, which flushes the bacte...

On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect? • Third spacing • This is normal and expected after a burn and it is benign • Document this finding as non-pitting abdominal edema. • Intravascular compartment syndrome - -Third Spacing You would suspect third spacing. Third-spacing is th...

Correct answer: 3 Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and ha...

Respiratory acidosis - pH low, PaCO2 high, K+ high. compensated by HCO3 high to bring pH to normal Metabolic acidosis - pH low, HCO3 low, K+ high compensated by PaCO2 low Respiratory alkalosis - pH high, PaCO2 low, K+ low. compensated by HCO3 low to bring pH to normal Metabolic alkalosis - pH high, HCO3 high, K+ low compensated by PaCO2 high Buffer system - CO2 + H2O = H2CO3 = H(+) + HCO3 What causes Metabolic alkalosis? - loss of hydrogen ions or acids or an excess of base bicarbon...

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition? - Respiratory alkalosis, compensated The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? - Metabolic alkalosis A client with a 3-day history of nausea and vom...

A nurse on a pediatric floor is teaching a newly licensed nurse about iv therapy. Which of the following information should the nurse include? a. Perform range of motion exercises on the extremity containing the IV site. b. Shave the client's hair if the IV is to be placed in the scalp. c. IV sites can be placed in the lower extremities up to the age of 2 years. d. Monitor the IV site, tubing, and connections every 4 hr. - a. Perform range of motion exercises on the extremity containing...