A nurse is caring for a patient with diabetes who is receiving insulin. The nurse should be most concerned if the patient experiences:

Correct Answer: C

Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.

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: B

Rationale: The correct answer is B because cleansing and dressing the wound is crucial in preventing further infection spread. First, cleansing the wound removes debris and pathogens, reducing the risk of infection. Second, dressing the wound protects it from external contaminants. This proactive approach promotes wound healing and prevents complications. A: Notifying the healthcare provider is important, but immediate wound care should be prioritized. C: Applying a dressing without cleansing the wound first may trap bacteria and worsen the infection. D: Pain medications are important for client comfort, but addressing the infection source is necessary for proper healing.

Correct Answer: B

Rationale: The correct answer is B: Hamburgers. Clients with hypercholesterolemia should decrease their intake of saturated fats and cholesterol. Hamburgers are typically high in saturated fats and cholesterol due to the ground beef patty and cheese. Broiled catfish (A) is a lean protein source and can be a healthier option. Wheat bread (C) is a good source of fiber and can help lower cholesterol levels. Fresh apples (D) are a healthy choice low in saturated fats and cholesterol. Therefore, hamburgers should be decreased in the diet to manage hypercholesterolemia effectively.

Correct Answer: B

Rationale: The nurse should first administer IV fluids when a client with a respiratory infection shows signs of sepsis. This is because sepsis can lead to severe dehydration and hypotension, and prompt fluid resuscitation is essential to stabilize the client's hemodynamic status. Administering antibiotics (choice A) is important but addressing fluid resuscitation takes precedence. Administering pain medication (choice C) may provide comfort but does not address the underlying issue of sepsis. Providing mechanical ventilation (choice D) may be necessary in severe cases but should be considered after addressing fluid resuscitation.

Correct Answer: A

Rationale: The correct answer is A: Body systems. This type of assessment promotes critical thinking by organizing data systematically based on different body systems, allowing for clustering of similar data and identification of patterns. Comprehensive assessments (B) may include body systems but lack the focused approach of promoting critical thinking. Head to toe assessments (C) are systematic but may not encourage clustering of data. Emergency assessments (D) prioritize immediate interventions rather than promoting critical thinking or clustering of data.

Correct Answer: B

Rationale: The main role of the nursing process in community health care is to provide individualized care frameworks. This involves assessing, diagnosing, planning, implementing, and evaluating care tailored to each patient's unique needs. Nursing interventions are personalized based on the individual's health status, preferences, and community resources. This approach promotes holistic and patient-centered care, leading to better health outcomes. The other choices are incorrect because: A: Implementing standardized treatment plans does not account for individual variations and needs. C: Nurses collaborate with diagnostic physicians but do not solely assist them. D: Establishing clinical guidelines is important but not the primary role of the nursing process in community health care.

Correct Answer: C

Rationale: The correct answer is C: small intestine. This is because the small intestine is where the majority of nutrient absorption takes place due to its large surface area and presence of villi for absorption. The stomach (A) primarily functions in digestion, not absorption. The pancreas (B) produces digestive enzymes but does not directly absorb nutrients. The gallbladder (D) stores bile produced by the liver to aid in digestion but does not participate in absorption directly.

Correct Answer: C

Rationale: The correct answer is C: Monitor for transfusion reactions. When a client receiving a blood transfusion develops chills, it may indicate a transfusion reaction, such as a febrile non-hemolytic reaction. The nurse's first priority is to monitor the client closely for other signs of a reaction, such as fever, rash, or shortness of breath. Stopping the transfusion may be necessary, but monitoring for reactions is crucial to identify and manage any adverse effects promptly. Vital signs should be monitored as part of assessing for reactions. Performing a lumbar puncture is not indicated in this situation and is unrelated to managing a transfusion reaction.