Correct Answer: A

Rationale: The correct answer is A: objective. Objective data refers to measurable and observable information obtained through physical examination or diagnostic tests. In this case, the nurse's documentation of the patient's respirations and pulse rate are objective data as they can be quantified and verified by any healthcare professional. This data is not influenced by personal feelings or interpretations, making it objective.


Choice B, reflective, is incorrect as it does not describe the nature of the data provided.
Choice C, subjective, is also incorrect because subjective data is based on the patient's feelings or perceptions, which is not the case here.
Choice D, introspective, is incorrect as it refers to internal self-reflection, not the nature of the data being documented.

Correct Answer: C

Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (
Choice
A) may startle the infant, asking the parent to undress the child (
Choice
B) can be done after the initial assessment, and beginning with the legs (
Choice
D) does not prioritize the critical areas of observation such as the head and face.

Correct Answer: B

Rationale: The correct answer is B because taking insulin only when blood sugar is high is incorrect and can lead to dangerous complications.
Step 1: Insulin should be taken as prescribed by the healthcare provider, not based solely on blood sugar levels.
Step 2: Checking blood sugar regularly (
A) is essential for diabetes management.
Step 3: Eating a balanced diet and exercising regularly (
C) are crucial for diabetes control.
Step 4: Reporting signs of infection to the healthcare provider (
D) is important due to diabetes-related complications.

Correct Answer: C

Rationale: The correct answer is C. The nurse should prevent infiltration of calcium to avoid tissue necrosis and sloughing. Infiltration of calcium can lead to severe tissue damage due to its caustic nature.
Therefore, the nurse should be vigilant in monitoring the IV site and ensuring proper placement to prevent this complication.


Choice A is incorrect because infusing hypertonic solutions rapidly can lead to fluid overload and electrolyte imbalances.
Choice B is incorrect because exceeding the recommended amount of potassium per liter of fluid can result in hyperkalemia, which can be dangerous.
Choice D is incorrect because calcium does not diminish digitalis's action; in fact, calcium can potentiate the effects of digitalis.

Correct Answer: D

Rationale:
Step 1: Establish rapport by showing interest in the patient's well-being.

Step 2: Emphasize continuity of care by referencing the previous visit.

Step 3: Encourage open communication about any changes or concerns.

Step 4: Initiate discussion on the patient's health status since the last visit.

Summary:
A -
Too broad and not focused on the patient's own health.
B - Assumes the patient has a specific reason for the visit.
C - Assumes the patient has hypertension and may not be relevant.
D - Encourages discussion on the patient's health status and continuity of care.