301 Exam #1 practice questions
The postoperative patient has an epidural morphine patient-controlled analgesia (PCA). Dose of each bolus = 1; Lockout = 6; Basal = 1. What is the maximum dose per hour this patient can receive? (enter number only)
11
which findings would the nurse anticipate in a patient with a new diagnosis of osteoarthritis? select all that apply a. negative rheumatoid factor (RF) b. increased electrolyte sedimentation rate (ESR) c. no inflammation in joint fluid d. increased serum creatine e. increased C-reactive protein (CRP)
a and c
a patient with laryngeal cancer has undergone a laryngectomy and is now receiving radiation therapy to the head and neck. the nurse would monitor the patient for which adverse effects of external radiation? select all that apply a. kerostomia b. stomatitis c. thrombocytopenia d. cystitis e. mucositis f. leukopenia
a, b, e
a patient who has apnea during sleep would require which of the following intervention? select all that apply a. refer to primary HCP b. restrict family members from sleeping in the same room c. assess sleep routine/ hours d. have the patient keep a sleep diary e. teach pursed lip breathing
a, c, d
the nurse receives evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. the first assessment of the patient the nurse should make is the: a. patient's temp b. the level of the patients pain c. the drainage on the nasal dressing d. the oxygen saturation by pulse oximetry
d. the oxygen saturation by pulse oximetry -this could kill them
It is 10 am, and the scheduling personnel for the Operating Room has been called and told that there is a patient with a history of GI bleeding, that had an endoscopy this morning and needs surgical intervention. Which of the following responses by the scheduling personnel is the most appropriate? a. "If you admit the patient to a floor for observation, we will get them in sometime today." b. "I will put them on the schedule for tomorrow morning, and if nothing emergent comes in they should be in by noon." c. "Since you are seeing the patient as an outpatient, do you think it could wait for another day or two?" d. "Have they been NPO (nothing by mouth) this morning? We can wait and see if anything opens up later this evening."
a. "If you admit the patient to a floor for observation, we will get them in sometime today."
a patient is having major abdominal surgery tomorrow. during pre-op teaching, the nurse teaches the patient how to do deep breathing exercises after surgery by telling the patient to a. "hold your abdomen firmly with a pillow, and take several deep breaths" b. "tighten your stomach muscles as you inhale, and breathe normally in an out of your mouth" c. "raise your shoulders to expand your chest and rib cage" d. "sit in an upright position and perform 'huff' breathing"
a. "hold your abdomen firmly with a pillow, and take several deep breaths" -not just for coughing, but deep breathing as well
a female patient's complicated history of signs and symptoms have finally led to the diagnosis of Lupus. which statement demonstrates the patient's need for future teaching about the disease a. "im hoping that surgery will be an option for me in the future" b. "ill try my best to stay out of the sun this summer" c. "I know that I probably have a high chance of getting arthritis" d. "I understand that im getting to be vulnerable to getting infections"
a. "im hoping that surgery will be an option for me in the future"
a 68-year-old scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. the best response by the nurse is a. "who is available to help you at home after the surgery" b. "I'm sure you will be able to manage at home after surgery. it is a simple procedure" c. "we will teach you everything you need to know to be able to care for yourself after surgery" d. "your health insurance will pay for inpatient care only if complications develop during surgery"
a. "who is available to help you at home after the surgery" -need more info
a patient is prescribed 325 mg/day of oral ferrous sulfate. the nurse includes in patient teaching "take your pill..." a. 1 hour before breakfast b. with dairy products c. and decrease fruits and juices in your diet d. along with a low residue diet
a. 1 hour before breakfast -take it by itself
The nurse is caring for an unresponsive patient that has been brought to the emergency room after a motor vehicle crash (MVC). The patient has been diagnosed with an aortic dissection that requires immediate surgical repair. There are no family members present, and the surgeon tells the nurse to assist with the transport to the OR. What should the nurse do about the informed consent? a. Go ahead and take the patient to the OR without the consent signed, there is no one present to sign it. b. Inform the surgeon that the consent is not signed and sign it in place of the patient. c. Call the hospital's legal representative and have them initial the consent, and then sign the document as a witness. d. Contact the emergency room chaplain and have them sign the consent form and then try to locate the next of kin.
a. Go ahead and take the patient to the OR without the consent signed, there is no one present to sign it.
the patient has a history of severe epistaxis. which lab value is of the most concern a. INR=4.5 b. Hbg=13.4 c. Hct=41% d. O2 sat=94%
a. INR=4.5 -should be 0.8-1.1, the higher the number the thinner the blood
the nurse cares for a patient who has Lupus. to preventing exacerbation of the condition, what should the nurse instruct the patient to avoid a. becoming fatigued b. animal dander c. dairy products d. nonsteriodal drugs
a. becoming fatigued
when developing a plan of care to manage a patient's pain from cancer, what should the nurse plan to do? a. individualize the pain medication regimen for the patient b. select medications that are least likely to lead to addiction c. administer pain medication as soon as the patient requests it d. change pain medications periodically to avoid drug tolerance
a. individualize the pain medication regimen for the patient
the patient diagnosed with osteoarthritis tells the nurse"my friend takes steroid pills for her rheumatoid arthritis. are steroids used for osteoarthritis too?" what should the nurse explain to the patient a. intra-articular corticosteroid injections can be used to treat osteoarthritis b. oral corticosteroids are used in osteoarthritis c. a systemic effect is needed in osteoarthritis d. rheumatoid arthritis and osteoarthritis are in fact treated withe the same medications
a. intra-articular corticosteroid injections can be used to treat osteoarthritis
the patient with sleep apnea asks why he has to wear an oral appliance every night. the nurse's response is based on the fact that an oral appliance's primary purpose is to: a. maintain patency of the oropharyngeal area b. keep the upper and lower teeth from touching c. provide positive pressure to the alveoli d. reduce tension in the mandibular muscles
a. maintain patency of the oropharyngeal area
after receiving change-of-shift report about the postoperative patients, which patient should the nurse assess first a. obese patine who had abdominal surgery 3 days ago and whose wound edges are separating b. patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. patient who has bibasliar crackles and a temp of 100 degrees on the first postoperative day after chest surgery d. patient who continues to have incisional pain 20 minutes after hydrocodone and acetaminophen (Vicoden) was given
a. obese patine who had abdominal surgery 3 days ago and whose wound edges are separating
a patient with a positive Mantoux test result is taking isoniazid for the treatment of TB. in assessing for side effects of this medication, the nurse should specifically include which of the following during the clinic visit? a. scleral assessment b. assess for peripheral edema c. assess for dyspnea d. note return rate of capillary refill
a. scleral assessment -isoniazid causes liver toxicity
the instructor reviewing "pneumonia" with the nursing student. which statement could be included in the conversation? a. streptococcus pneumonia is the most common causative organism b. CAP has a higher mortality than HAP c. all pneumonia can be treated with antibiotics d. vomiting is a prerequisite for aspiration pneumonia
a. streptococcus pneumonia is the most common causative organism - HAP is more dangerous than CAP
a patient is brought to an ED in an unconscious condition. the hemoglobin level of the patient is 20 g/dL. how should the nurse interrupt the lab result? a. the patient is dehydrated b. the patient has anemia c. the patient has internal hemorrhage d. the patient has fluid volume excess
a. the patient is dehydrate -hemoglobin goes up ----> plasma goes down
a patient who has been newly diagnosed with Lupus has been admitted to the med-surg unit. the nurse anticipates which diagnostic finding related to the disease a. thrombocytopenia b. elevated hemoglobin level c. negative antinuclear antibodies (ANA) d. glucosuira
a. thrombocytopenia
a patient has been taking opioid analgesics for more than 2 weeks to control his post-surgical pain. while the surgeon is pleased with his healing progress, he wants to change the analgesic to a non-opioid drug. he prescribes a gradually lower opioid dose and increasingly larger non-opioid drug doses. why is the surgeon changing medications in this manner a. to avoid withdrawal symptoms b. to avoid addiction c. to avoid tolerance d. to avoid respiratory depression
a. to avoid withdrawal symptoms -tolerance is the need for more drugs to feel more affect. withdrawal is getting cut off
The patient is in distress. Sat ABG's are drawn. Results are pH 7.32, pCO2 38, HCO3 19. which findings in the patient's chart would be consistent with this problem? a. uncontrolled diabetes b. uncontrolled vomiting c. excessive opioids d. uncontrolled anxiety
a. uncontrolled diabetes -uncompensated metabolic acidocis
Surgery is not without risks. Therefore, patients receive a lot of information and pre-operative teaching to try and limit complications. Which of the statements below is correct in regards to pre-operative teaching? (select all that apply) a. If you have a latex allergy, you will need to be pre-medicated with diphenhydramine (Benadryl) prior to surgery b. If you smoke, you should stop smoking at least 6 weeks prior to surgery c. The only way to know if you will have malignant hyperthermia, is to actually have a surgery d. Occasional alcohol use is not necessary to mention, but illicit drug use is important to be honest about e. It is okay to share anything that seems important to you, even if it isn't asked about specifically
b, c, e
The nurse is completing the pre-op admission assessment of a patient that will be having gastric by-pass surgery. The patient says, "I have been waiting for years to have this surgery so that there wouldn't be any real risks to it." Which of the following statements by the nurse would be the most appropriate? a. "I am sure you must be excited now that the time has come." b. "Can you tell me a little more about what risks you are aware of?" c. "I think I better call the surgeon and have them come and talk to you again." d. "Are you sure you aren't nervous about anything?"
b. "Can you tell me a little more about what risks you are aware of?"
The nurse is talking with a patient that is scheduled for surgery in 3 hours. The nurse asks the patient if they have remained NPO (nothing by mouth) overnight. The patient replies that they had some coffee for breakfast, but they didn't eat any food. The nurse knows that which of the following responses is correct? a. "Oh no, nothing by mouth—means, nothing. I will contact the team. I am afraid we may have to postpone your surgery." b. "That should be fine as long as the coffee was black. Did you use any cream or sugar in it?" c. "Your stomach need to remain empty for at least 6 hours after having fluids. I think we can switch your time, but I have to check." d. "Was it more than 8 oz? If so, we will probably have to cancel the surgery for today."
b. "That should be fine as long as the coffee was black. Did you use any cream or sugar in it?"
a patient who is to receive external radiation for cancer says to the nurse, "my family and friends say that I will get a radiation burn." which response by the nurse is best? a. "a daily application of emollient will prevent the burn" b. "a localized skin reaction does usually occur" c. "it will be no more than a sun burn" d. "they may be misinformed"
b. "a localized skin reaction does usually occur"
the. nursing student is reviewing facts about the shiley tracheostomy's to the patient and his wife, as he is undergoing a tracheostomy in the morning. which statement could be included in the discussion? a. "shiley trachs are metal" b. "shiley trachs have a string with an inflatable balloon attached" c. "shiley trachs have a reusable inner cannula" d. "shiley trachs do not need an obturator to be inserted"
b. "shiley trachs have a string with an inflatable balloon attached"
a nurse is reviewing the medical record of a male patient with cancer. the HCP has prescribed figastrim 400 mcg, sub q once daily. the nurse reviews the laboratory report and determines treatment has been effective when: a. Hbg> 12 g/dL b. WBC> 3,500/mm3 c. platelets> 92,000/mm3 d. Hct> 35%
b. WBC> 3,500/mm3 -filgastrim increases neutrophil count
A patient has been receiving chemotherapy. Upon assessing the patient during morning rounds, the nurse notes the patient is now bleeding from the two old IV sites and his gums. Stool is positive for blood as well. The patient is requesting to sit up in the chair. The nurse implements which intervention at this time? a. monitor vitals once a shift b. apply pressure to bleeding sites c. assist the patient to the chair d. place the patient in neutropenic precautions
b. apply pressure to bleeding sites
a patient in end-stage kidney disease is prescribed epoetin (Epogen). before administering the first dose, the nurse should: a. check to see if the patient has any difficulty swallowing b. assess the hemoglobin level c. hold the medication if the BUN is elevated d. administer diphenhydramine (Benadryl)
b. assess the hemoglobin level -if over level is over 10, do not give
a 92 year old woman has bilateral osteoarthritis of the knees. the nurse teaches the patient that the most beneficial measure to protect the joints is to a. use a wheelchair to avoid walking as much as possible b. exercise regularly and maintain a well-balanced diet c. use a cane for ambulation to relieve the pressure on the hips d. avoid sitting at a 90 degree angle or full flexion of the knees
b. exercise regularly and maintain a well-balanced diet
the patient with chronic bronchitis is admitted to the med-surg unit. the best help this patient maintain a patent airway and achieve maximal gas exchange, the nurse should a. administer scheduled anxiolytics daily to control related anxiety b. instruct the patient to drink 2 L of fluid daily c. administer pain medication as ordered d. maintain the patient on bed rest
b. instruct the patient to drink 2 L of fluid daily
A patient is experiencing osteoarthritis. Which finding on the x-ray report of this patient indicates that the patient is developing a permanent limitation of motion? a. increased synovial fluid b. joint space narrowing c. a thickened synovial membrane d. dislocation of the joint
b. joint space narrowing
a nurse is caring for a patient in PACU who has received general anesthesia. during the immediate postoperative period, which nursing acton takes the highest priority a. checking the dressing for bleeding b. maintain a patent airway c. monitoring the vital signs d. promoting urine output
b. maintain a patent airway -ABCs
five minutes after receiving the orders preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. which action by the nurse is most appropriate? a. carefully assist the patient to the bathroom b. offer the patient a urinal or bedpan c. as the paint to what until the drug has past it peak action d. tell the patient that a bladder catheter will be placed in the operating room
b. offer the patient a urinal or bedpan -reduce risk for falls
a patient is admitted to the hospital with the idiopathic aplastic anemia. which of these collaborative problems will the nurse include when developing the care plan a. potential complication : seizures b. potential complication: infection c. potential complication: hypokalemia d. potential complication: pulmonary edema
b. potential complication: infection - all blood cells are low, including WBCs so risk for infection
when caring for a patient with lupus, the nurse recognizes which is the most serious complication of the disorder a. polycythemia b. renal failure c. hepatitis d. hypothyroidism
b. renal failure
which symptom indicates the patient with TB is contagious? a. postive Mantoux test b. sputum positive for AFB c. weight loss and night sweats d. calcification noted on CXR
b. sputum positive for AFB - you would just confirm you have TB on the CXR, not that its contagious
a patient with many home related responsibilities is diagnosed with osteoarthritis she tells the nurse she is concerned that the disease will prevent her from doing her chores. which suggestion should the nurse. offer? a. "do all your chores in the morning , when pain and stiffness are least pronounced" b. "do all your chores right after performing morning exercises to loosen up" c. "pace yourself and rest frequently, especially after activities" d. "do all your chores in the evening, when pain and stiffness are least pronounced"
c. "pace yourself and rest frequently, especially after activities"
the patient with a history of severe emphysema and is a known CO2 retainer is admitted to the hospital to have an elective surgery performed tomorrow. routine baseline ABG's are performed preoperatively. the patient is in no acute distress. which ABG results are consistent with this scenario (pH_____, pCO2_______, HCO3______) a. 7.30, 60, 27 b. 7.50, 22, 27 c. 7.35, 65, 35 d. 7.45, 22, 35
c. 7.35, 65, 35 -fully compensated respiratory acidosis
A patient is receiving IV therapy through a non-tunneled subclavian CVC. The patient is reporting pain in the chest and shoulder. Upon taking V.S., the nurse notes: T - 101.2; P - 116 & thready; R - 24 & dyspneic; BP has dropped to 86/48. What complication would the nurse suspect? a. Circulatory overload due to infusion of fluid b. Air embolism c. Systemic infection d. Infiltration at the site of insertion
c. Systemic infection
The nurse is caring for a patient that is scheduled for tonsillectomy because of frequent infections. The nurse knows that this surgery is semi-elective based on which of the following statements? a. This is an urgent medical condition, and needs to be completed within 2 hours b. There will be significant complications if not completed within 24 hours c. Though a priority, this is a low mortality risk surgery d. This surgery is only being done because the patient wants to have it
c. Though a priority, this is a low mortality risk surgery
The patient is going to surgery tomorrow. The nurse collaborates with the patient when developing the teaching plan. What is the primary purpose of preoperative teaching? a. To determine whether the patient is psychologically ready for the surgery. b. To discuss the types of anesthesia that will be used for the surgery. c. To reduce the risk of postop complications. d. To explain the risks associated with the surgery.
c. To reduce the risk of postop complications.
the nurse is making patient rounds following shift report. which patient should the nurse assess first a. a 38 yr old woman receiving internal radiation for cervical cancer b. a 77 yr old man with lung cancer hospitalized for induction of high-dose chemotherapy c. a 75 yr old man with metastatic prostate cancer with a fracture of the femur who is in pain d. a 33 yr old woman with cancer undergoing surgery for placement of a CVC
c. a 75 year old man with metastatic prostate cancer with a pathologic fracture of the femur who is in pain -most unstable
the nurse is caring for a patient receiving a chemotherapy drug in a peripheral line that is a potential vesicant. the patient is currently not a candidate for a central line. the patient c/o pain at insertion site; redness noted. which nursing action would be included in the follow up care a. slow the infusion rate while notifying the HCP b. restart the infusion distal of the dc'd IV site c. assess the patient for skin sloughing d. hold the site below the level of the heart
c. assess the patient for skin sloughing
the patient has a bone marrow aspiration performed. after the procedure, what is the FIRST nursing action a. position the patient on the affected side b. cleanse the site with an antiseptic solution c. briefly apply pressure over the aspiration site d. begin frequent monitoring of the parents vital signs
c. briefly apply pressure over the aspiration site
the nurse is making rounds and observes the patient receiving oxygen from a non-rebreather mask. the nurse should a. position the mask lower on the patients face b. verify that the reservoir bag remains deflated c. confirm that the flow rate is set to deliver 10L/min d. loosen the elastic band on the patient's face
c. confirm that the flow rate is set to deliver 10L/min -the bag should be partially inflated
a nurse is caring for the patient who has developed dysphagia and is unable to swallow. the patient is receiving around the clock opioid pain medications for cancer pain and hospice has recently begun caring for the patient. what is the best nursing intervention in preparing for the patient's discharge a. contact the patient's HCP to ask to substitute a liquid form of meds for the pill form b. teach the patient and family members to crush the pills and administer them with applesauce c. contact the patient's HCP to discuss use of transdermal medications for pain control d. teach the patient and family members about addiction that may occur as a result of regular opioid use
c. contact the patient's HCP to discuss use of transdermal medications for pain control
on admission of a patient to the post anesthesia care unit (PACU), the BP is 122/72. thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry, skin. which action by the nurse is most appropriate a. increase the IV fluid rate b. notify the anesthesia care provider c. continue to take vital signs every 15 minutes d. administer oxygen therapy 100% per mask
c. continue to take vital signs every 15 minutes -expected finding
The nurse is examining a female patient with a possible new diagnosis of rheumatoid arthritis. The nurse should ask the patient if she is having: a. limited range of motion b. dizziness c. fatigue d. nausea
c. fatigue
which of the following findings would be expected in a patient with chest trauma, rib fractures, and respiratory acidosis? a. Kussmaul respirations due to inability to take deep breaths b. a massive diffusion disturbance due to rib fractures c. hypoventilation due to inability to take deep breaths because of pain d. hyperventilation due to inability to take deep breaths, so short fast breaths are more comfortable
c. hypoventilation due to inability to take deep breaths because of pain -respiratory acidosis----> hypoventilation
a patient with Lupus is getting ready for discharge. the nurse knows the patient has understood the patient teaching when the patient states she needs to what a. get as much exposure the sunlight as possible to help control skin rashes b. be as active as possible between flare ups c. monitor body temp regularly d. stop her corticosteroids when symptoms are relieved
c. monitor body temp regularly
a patient with gout should be assessed by the nurse for which complications a. cirrhosis b. gastric ulcer c. renal calculi d. pulmonary emboli
c. renal calculi
which HCP order should the nurse implement first a. explain the patient NPO status b. insert the nasogastric tube and hook to suction c. take vital signs d. insert the IV and start IVFs
c. take vital signs - assess vs implement
the nurse is assessing a patient in PACU, who is recovering postoperatively form general anesthesia. the patient can give his name but is not sure about where he is or the time of day. what should the nurse do next a. notify the surgeon b. rub the patient's sternum to arouse the patient c. tell the patient where he us and the time of day d. take the patient's blood pressure
c. tell the patient where he us and the time of day -expected finding
a patient is 5 hours s/p abdominal surgery. the oncoming nurse notes in report that there has been no drainage boded from the Hemovac since surgery. which finding may explain the absence of drainage a. the patient has ben lying on his side for 2 hours with the drain positioned upward b. the patient has a nasogastric tube in place that drained 400 ml c. the Hemovac drain isn't compressed; instead its fully expanded d. there is a moderate amount of dry drainage on the outside of the dressing
c. the Hemovac drain isn't compressed; instead its fully expanded -must be compressed to start the suction
the nurse is suctioning the patient's tracheostomy's. for what reason during the procedure does the nurse complete the below action a. to lubricate the outside of the suction catheter b. to prime the tubing with air c. to clear secretions from the tubing d. to regulate the suction pressure
c. to clear secretions from the tubing
after 3 months of supplemental iron therapy, there is no significant increase in the patient's hemoglobin level. Iron dextran is prescribed. what is the best ay for the nurse to administer this medication a. with a transdermal needle b. by massaging the injection site c. with the use of the Z-track method d. by administering at a 45 degree angle
c. with the use of the Z-track method
a patient with pernicious anemia is receiving parenteral vitamin b12 therapy. which patient indicates effective teaching about this therapy a. "I will receive parenteral vitamin b12 therapy until my signs and symptoms disappear" b. "I will receive parenteral vitamin b12 therapy until my vitamin b12 levels returns to normal" c. "I will receive parenteral vitamin b12 therapy monthly for 6 months to a year" d. "I will receive parenteral vitamin b12 therapy for the rest of my life"
d. "I will receive parenteral vitamin b12 therapy for the rest of my life"
The patient who has been hospitalized for four weeks is receiving TPN through a central venous catheter (CVC). The patient asks the nurse why this type of catheter is being used instead of a regular peripheral IV. Which is the best nursing response for this patient? a. "A central venous catheter was inserted because your peripheral veins could no longer be used." b. "The central venous catheter allows nutrients to be administered at a much higher rate." c. "The TPN solution is hypotonic and can be given only through a central venous catheter." d. "The nutrients that are being administered are too concentrated for a peripheral IV."
d. "The nutrients that are being administered are too concentrated for a peripheral IV."
which statement by a patient undergoing external radiation therapy indicates the need for further teaching a. "ill wash my skin with mild soap and water only" b. "ill not use my heating pad during my treatment" c. "ill wear protective clothing when outside" d. "im worried ill expose my family members to radiation"
d. "im worried ill expose my family members to radiation"
after a knee replacement, the patient has a SCD. what is a related nursing intervention a. elevate the SCD on 3 pillows b. change the settings on the SCD to make the patient more comfortable c. stop the SCD to remove dressings and bathe the legs d. discontinue the SCD when the patient is ambulatory
d. discontinue the SCD when the patient is ambulatory
an obese, malnourished patient has undergone abdominal surgery. while ambulating on the 4th post-op day, she complains to the nurse that her dressing is saturated with drainage. before this activity, the dressing was dry and intact. which is the best initial action for the nurse to take a. splint the abdomen with a pillow and call the surgeon b. administer oxygen per nasal cannula c. reinforce the existing dressing with another dressing d. lift the dressing to assess the wound
d. lift the dressing to assess the wound
the teaching plan for the patient with rheumatoid arthritis includes rest promotion. what position of the involved joints should the nurse tell the patient to avoid when at rest a. keeping all joints aligned b. elevating the affected joints c. lying in a prone position d. maintaining the joints in a flexed position
d. maintaining the joints in a flexed position
the nurse is caring for a patient with rheumatoid arthritis who is receiving NSAIDS. which intervention included in the care plan will help the nurse provide safe and effective care a. provide a potassium-rich diet b. administer Vitamin C supplements c. teach deep breathing and Kegel exercises d. monitor for symptoms of gastrointestinal distress
d. monitor for symptoms of gastrointestinal distress
A female patient with iatrogenic alopecia has been unable to return to work for 10 days following chemotherapy as a result of ongoing fatigue and inability to perform usual activities. Lab results are WBC's = 1800/mm3, Hgb/Hct = 11.3/30.9%, platelets = 99,000. The nurse notes the patient is anxious. Which of the following is the priority nursing diagnosis at this time? a. anxiety related to role change b. activity intolerance related to deficient blood cells c. body image disturbance related to effects of chemotherapy d. risk for infection related to inadequate defenses
d. risk for infection related to inadequate defenses