A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

Correct Answer: D

Rationale: The correct answer is D because upper extremity swelling in a client with a PICC can indicate a potential complication such as a blood clot or infection, which requires immediate attention to prevent serious complications. Swelling can impede blood flow and cause further issues. A: The initial site dressing being 3 days old may indicate a need for dressing change but does not require immediate attention. B: The PICC being inserted 4 weeks ago is relevant for assessing infection risk but does not require immediate attention. C: Absence of a securement device is important for preventing catheter dislodgement but does not require immediate attention compared to potential complications like swelling.

Correct Answer: B

Rationale: The correct answer is B: teaching. Teaching is a common need for all patients in ambulatory care facilities to ensure they understand their conditions, treatments, and self-care. This empowers patients to make informed decisions and manage their health effectively. Referrals (A) are not always needed for every patient, and advocacy (C) may be necessary but not a universal need. Surgery (D) is a specific intervention that only applies to a subset of patients, not a common need for all patients in ambulatory care.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Ensuring medical and surgical safety is crucial to prevent complications during surgery. 2. Health history and physical assessment help identify potential risks and tailor care plans accordingly. 3. It allows the nurse to assess the patient's readiness for surgery and identify any contraindications. 4. This data informs decision-making, ensures appropriate interventions, and enhances patient outcomes. Summary: - Option A is incorrect because nurse-patient relationships are important but not the primary focus in this context. - Option C is incorrect as the importance of the assessment goes beyond routine procedure. - Option D is incorrect as the main goal is to ensure safety and address potential issues.

Correct Answer: A

Rationale: The correct answer is A: problem-oriented medical record (POMR). In POMR, patient information is organized around patient diagnoses, facilitating a systematic approach to patient care. This method focuses on identifying and managing patient problems, promoting continuity and efficiency in healthcare delivery. Incorrect choices: B: Source-oriented record - Organizes information based on the source of the data, not patient diagnoses. C: PIE charting system - Focuses on problem, intervention, and evaluation, but not solely on patient diagnoses. D: Focus charting - Centers on specific patient concerns and focuses on addressing them, but does not primarily organize information around diagnoses.

Correct Answer: A

Rationale: The correct answer is A because helping a patient prepare a living will is an ethical/legal skill that involves respecting the patient's autonomy and ensuring their wishes are documented. This action aligns with the principles of patient advocacy and informed consent. In contrast, obtaining a urine sample (B) is a technical skill, explaining a plan of care (C) is a communication skill, and holding a patient's hand (D) is a compassionate gesture but not necessarily an ethical/legal skill. Ultimately, the ability to facilitate a patient's decision-making process regarding their care and treatment options reflects a nurse's commitment to upholding ethical and legal standards in healthcare practice.