A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Risk for infection related to chest x-ray procedure
Impaired gas exchange related to alveolar-capillary membrane changes
Risk for deficient fluid volume related to dehydration
Ineffective breathing pattern related to pneumonia
The Correct Answer is B
A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.
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Correct Answer is ["B","C","D","E","F"]
Explanation
A. This statement is incorrect; the nurse should touch only the inside of the first glove while putting it on to maintain sterility.
B. The outer glove package should be removed by tearing it open to access the gloves inside.
C. After putting on the second glove, interlocking hands helps to ensure that the gloves remain sterile.
D. Slipping fingers underneath the second glove cuff with the gloved dominant hand helps to keep the gloves sterile while donning them.
E. Laying the glove package on a clean flat surface above the waistline prevents contamination.
F. The dominant hand should be gloved first to maintain a sterile technique, as the dominant hand is used for the procedure.
Correct Answer is A
Explanation
A. Compassion fatigue is characterized by burnout and secondary traumatic stress, which result from prolonged exposure to caring for patients in distress and trauma, leading to emotional exhaustion.
B. Lateral violence and intrapersonal conflict involve hostile behavior and internal personal issues, which do not define compassion fatigue.
C. While physical and mental exhaustion can occur with compassion fatigue, they are not the defining aspects without the context of prolonged trauma exposure.
D. Short-term grief and a single stressor do not capture the chronic nature of compassion fatigue, which builds over repeated exposure to others' suffering.