A nurse is assisting a postoperative patient with deep-breathing exercises. Which of the following is an accurate step for this procedure?

Correct Answer: D

Rationale: In the context of basic nursing care needs, deep-breathing exercises are crucial postoperatively to prevent complications like atelectasis. Option D, asking the patient to hold their breath for 3 to 5 seconds, is the correct step in this procedure. This technique helps to fully expand the lungs, improving ventilation and oxygenation. Option A is incorrect because placing the patient in a prone position is not conducive to effective deep-breathing exercises. Option B is incorrect as feeling the chest rise does not necessarily ensure proper lung expansion. Option C is also incorrect as rapid exhalation and inhalation can lead to hyperventilation rather than deep breathing. Educationally, it is important for nurses to understand the rationale behind deep-breathing exercises to provide optimal postoperative care. By explaining the correct technique and the reasons why other options are incorrect, nurses can ensure patient safety and recovery. Training in proper techniques for postoperative care is essential for nurses to provide holistic patient care.

Correct Answer: B

Rationale: In a patient on prolonged bedrest with high levels of urinary calcium, the correct risk posed is option B) renal calculi (kidney stones). This occurs because when calcium levels in the urine are elevated, there is an increased likelihood of calcium crystals forming in the kidneys, leading to the development of kidney stones. Option A) urinary calcium is not a concern is incorrect because elevated urinary calcium levels can indeed lead to complications like kidney stones. Option C) increased urinary output is not directly related to high urinary calcium levels. Option D) imbalanced intake/output is a general statement and does not specifically address the risk associated with high urinary calcium levels. Educationally, understanding the implications of high urinary calcium levels in patients on prolonged bedrest is crucial for nurses providing care. This knowledge helps in early identification of potential complications like kidney stones, allowing for timely interventions and preventive measures to be implemented, thus improving patient outcomes and quality of care. It also emphasizes the importance of monitoring laboratory results and understanding the significance of each parameter in patient care.

Correct Answer: A

Rationale: The correct answer is A) Social Isolation. In this scenario, the constant dribbling of urine experienced by the older adult woman can lead to physical discomfort, unpleasant odor, and embarrassment. These factors can contribute to her withdrawing from social interactions and activities due to fear of judgment or embarrassment related to her urinary incontinence. Social isolation is a common consequence of such conditions, where individuals may avoid social situations to prevent potential humiliation or discomfort. Option B) Impaired Adjustment is less relevant in this case as it typically relates to difficulty in adapting to life changes or stressors, which may not be the primary concern here. Option C) Defensive Coping involves unconscious strategies to protect oneself from psychological harm. While this may play a role in how the woman copes with her condition, it is not directly related to the social consequences of urinary incontinence. Option D) Impaired Memory is not the most appropriate diagnosis for this situation as there is no direct link between memory impairment and the symptoms described. From an educational perspective, understanding the impact of urinary incontinence on an individual's social and emotional well-being is crucial for nurses. By recognizing the potential for social isolation in patients experiencing urinary incontinence, nurses can implement appropriate interventions to address not only the physical symptoms but also the psychosocial implications of the condition. This case highlights the importance of holistic nursing care that considers the emotional and social needs of patients alongside their physical symptoms.

Correct Answer: D

Rationale: The correct answer is D) it disturbs normal peristalsis and bowel motility. Rationale: Palpating the abdomen last during an abdominal assessment is crucial because palpation can disrupt normal peristalsis (the wave-like movements of the intestines) and bowel motility. By palpating the abdomen last, the nurse allows the other assessment techniques (inspection, auscultation, and percussion) to be performed without disturbing the natural bowel sounds and movements. This ensures a more accurate assessment of the patient's abdominal condition. Option A) it is the most painful assessment method and Option B) it is the most embarrassing assessment method are incorrect because the rationale for palpating the abdomen last is not related to pain or embarrassment. It is primarily about ensuring an accurate assessment. Option C) to allow time for the examiner's hands to warm is incorrect because while it is important for the examiner's hands to be warm to provide comfort to the patient, this is not the primary reason for palpating the abdomen last. Educational context: Understanding the rationale for the sequence of abdominal assessment techniques is essential for nursing students and healthcare professionals to conduct thorough and accurate assessments. By following the proper sequence, nurses can gather comprehensive information about the patient's abdominal health while minimizing any disruptions to normal physiological processes.

Correct Answer: C

Rationale: In the context of basic nursing care needs of the patient, understanding the importance of risk assessments in healthcare settings is crucial for ensuring patient safety and staff well-being. The correct answer is C) 5 employees. This means that in an organization with 5 or more employees, risk assessments must be recorded. This is because as the number of employees increases, the complexity and diversity of risks also tend to increase. By requiring risk assessments to be recorded in organizations with 5 or more employees, it ensures that potential risks are identified, managed, and mitigated effectively. Option A) 1 employee is incorrect because in smaller organizations with only one employee, the need for formal recording of risk assessments may be less stringent due to the more direct oversight and control possible in such a setting. Option B) 2 employees is incorrect because, similarly to the rationale for option A, in very small organizations with only two employees, the need for formal recording of risk assessments may not be as critical as in larger organizations. Option D) 10 employees is incorrect because the threshold for requiring risk assessments to be recorded is set at 5 employees, as mentioned earlier. Beyond this number, the complexity of operations and potential risks necessitate formal documentation of risk assessments to ensure comprehensive risk management strategies are in place. In the educational context, understanding the legal and ethical obligations related to risk assessments in healthcare is essential for nursing professionals. By knowing the minimum threshold for recording risk assessments based on the number of employees in an organization, nurses can contribute to creating a safe and secure environment for both patients and staff.