A hospitalized client has the following blood lab values: WBC 3,000/ul, RBC 5.0 (X 106), platelets 300, 000, what would be a priority nursing intervention?

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.

Correct Answer: B

Rationale: The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal. Incorrect choices: A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull. C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction. D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.

Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.

Correct Answer: B

Rationale: The correct answer is B: Chlamydia collection kit. The primary care provider will need the collection kit to gather a sample for testing. A Chlamydia slide (A) is not necessary as the provider needs to collect a sample first. A Chlamydia swab (C) is used to collect the sample, not to provide to the provider. A Chlamydia wet mount (D) is not appropriate for Chlamydia testing, as it is typically used for other types of infections.

Correct Answer: D

Rationale: The correct answer is D: Dependent. In this scenario, the nurse is administering pain medication based on a healthcare provider's prescription, which demonstrates a dependent nursing intervention. The nurse is reliant on the provider's order to carry out this action. Collaborative interventions involve working with other healthcare professionals, independent interventions are actions that nurses can initiate without supervision, and interdependent interventions involve mutual goal-setting and decision-making among healthcare team members.

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.

Correct Answer: A

Rationale: The correct answer is A: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being. Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.

Correct Answer: A

Rationale: The correct answer is A because evaluating a nursing intervention involves collecting data to determine if the goals set for the intervention were achieved. This process helps in assessing the effectiveness of the intervention in meeting the desired outcomes. Option B is incorrect as it refers to the identification of nursing diagnoses for new problems, which is part of the nursing assessment phase, not evaluation. Option C is incorrect as adjusting the care plan to include collaborative interventions is part of the implementation phase, not evaluation. Option D is incorrect as performing client care tasks as per protocol is part of the implementation phase, not evaluation.

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing and the type of drainage present, then will progress to more specific assessments based on the findings. This approach allows for a systematic and comprehensive evaluation of the patient's condition by moving from general observations to detailed examinations. Explanation: 1. General assessment: The nurse is initially assessing the overall appearance of the surgical dressing and the type of drainage. 2. Specific assessment: Based on the initial findings, the nurse will proceed to conduct more focused assessments, such as checking for signs of infection, monitoring vital signs, and assessing the surgical site for any complications. Other choices are incorrect: A: Gordon’s Functional Health Patterns - This framework focuses on assessing different aspects of an individual's health patterns, such as activity level, sleep patterns, and coping mechanisms. It is not the most appropriate approach in this situation. B: Activity-exercise pattern assessment - This type of assessment focuses