Questions and Answers
, The nurse caring for a resident of a long-
kr kr kr kr kr kr kr kr kr
term care facility discovers the client has a body temperature of 102 F, nasal congestion, and body a
kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr
ches. The provider diagnosed the resident with influenza the day prior. Which nursing diagnosis do
kr kr kr kr kr kr kr kr kr kr kr kr kr kr
es the nurse determine applies to this client?
kr kr kr kr kr kr kr
A. Hyperthermia related to the body's inflammatory response to invading pathogens
kr kr kr kr kr kr kr kr kr kr
B. Ineffective airway clearance related to thick and tenacious bronchial secretions.
kr kr kr kr kr kr kr kr kr kr
C. Risk for altered thought processes (dementia) related to advanced age
kr kr kr kr kr kr kr kr kr kr
D. Risk for infection related to hyperthermia, nasal congestions, and body aches
kr kr kr kr kr kr kr kr kr kr kr
A. Hyperthermia related to the body's inflammatory response to invading pathogens
kr kr kr kr kr kr kr kr kr kr
The nurse notes that a client with pneumonia is experiencing a decrease in oxygen saturation and d
kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr
etermines the client's nursing diagnosis is "Impaired gas exchange". Which statement or related fac
kr kr kr kr kr kr kr kr kr kr kr kr kr
tors does the nurse determine is the etiology of this nursing diagnosis?
kr kr kr kr kr kr kr kr kr kr kr
A. Alveolar-capillary membrane exchange
kr kr kr
B. Cough, chest pain, and fever
kr kr kr kr kr
C. Pneumonia
kr
D. Respiratory illness A. Alveolar-capillary membrane exchange
kr kr kr kr kr
The nurse notes that a client has the nursing diagnosis of "Fluid volume deficit related to an inability
kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr
to swallow". Which outcome criterion is appropriate for the nurse to set for this client?
kr kr kr kr kr kr kr kr kr kr kr kr kr kr kr
A. The client's fluid intake will be adequately restored.
kr kr kr kr kr kr kr kr