A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?

Correct Answer: C

Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client. Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.

Correct Answer: B

Rationale: The correct answer is B: The catheter should remain in place for 1-2 days. After litholapaxy surgery, the urethral catheter is typically removed within 1-2 days to prevent infection and promote healing. Keeping the catheter in place for too long can increase the risk of complications such as urinary tract infections. Options A, C, and D suggest longer durations which are not necessary and may lead to unnecessary discomfort and risks for the client. Therefore, the optimal timeframe for catheter removal post-litholapaxy surgery is within 1-2 days.

Correct Answer: D

Rationale: The correct answer is D because 1 beef cube contains about 1,000mg of sodium. To reach 1,600mg, the patient needs an additional 600mg. 12oz of tomato juice contains approximately 600mg of sodium, making it the right choice. A: Not enough sodium from the beef cube and tomato juice. B: Too much sodium from the 16oz of tomato juice. C: Too much sodium from the 4 beef cubes.

Correct Answer: C

Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.

Correct Answer: A

Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow. Incorrect choices: B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties. C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties. D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.