Correct Answer: B

Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.

Correct Answer: C

Rationale: The barrier to goal setting between the nurse and the family in this scenario is the failure of the family to perceive the existence of the problem. Goal setting in healthcare generally requires mutual agreement and understanding between the healthcare provider (nurse) and the patient/family. If the family does not perceive that there is an existing problem that needs to be addressed, there will likely be resistance or lack of motivation to set goals and work towards resolving the issue. This barrier can hinder effective communication, collaboration, and ultimately, the successful achievement of healthcare goals. It is important for the nurse to address this barrier through education, communication, and building trust to ensure that all parties are on the same page and actively participate in goal setting and care planning.

Correct Answer: A

Rationale: Shoulder dystocia is an obstetric emergency where one of the baby's shoulders becomes impacted behind the mother's pubic bone after the head delivers. This can lead to compression of the umbilical cord and compromise fetal oxygenation. The most critical nursing intervention in managing shoulder dystocia is applying suprapubic pressure to dislodge the impacted shoulder and allow for delivery of the baby. By gently pushing downwards on the mother's abdomen just above the pubic bone, the shoulder can be released, and the baby can be delivered successfully. This intervention should be prioritized to prevent potential complications for both the mother and the baby. Episiotomy may be considered if necessary, but it is secondary to addressing the shoulder dystocia. Oropharyngeal airway insertion and administering magnesium sulfate are not indicated in the immediate management of shoulder dystocia.

Correct Answer: A

Rationale: Grilled chicken breast is a suitable choice for a low-phosphorus diet because poultry is typically lower in phosphorus compared to dairy products (like cheese), nuts (like almonds), and whole grains (like wheat toast). This option indicates an understanding of the need to restrict phosphorus intake, which is important for individuals with chronic kidney disease to prevent complications.

Correct Answer: B

Rationale: A severe headache is a classic sign of a hemorrhagic stroke. Hemorrhagic stroke occurs when a blood vessel in the brain ruptures and causes bleeding. This bleeding can lead to increased pressure within the skull, resulting in a sudden and severe headache. Other symptoms of a hemorrhagic stroke may include nausea, vomiting, sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, and loss of coordination. It is important to seek immediate medical attention if someone is experiencing symptoms of a stroke, including a severe headache, as prompt treatment is crucial in minimizing damage and improving outcomes.