A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Correct Answer: A

Rationale: The correct answer is A: Hydrocolloid dressing. For a stage 2 pressure injury, a hydrocolloid dressing is ideal as it maintains a moist environment to promote healing, absorbs excess exudate, and provides a barrier against bacteria. Transparent dressings (B) are more suitable for superficial wounds. Gauze dressings (C) may adhere to the wound bed and cause trauma upon removal. Alginate dressings (D) are better for wounds with heavy exudate, not typically seen in stage 2 pressure injuries.

Correct Answer: A

Rationale: The correct answer is A: Fixed budget. A fixed budget is set without considering changes that may occur during the year. It remains unchanged regardless of actual performance. In this scenario, the budgeted amounts are predetermined and do not adjust based on changing conditions. Other choices are incorrect because: - B: Zero-based budget requires justifying every expense from scratch, not pre-set amounts. - C: Variable budget adjusts based on activity levels, not predetermined like in this case. - D: Operating budget encompasses all revenues and expenses, not necessarily fixed like in this scenario.

Correct Answer: D

Rationale: The correct answer is D: affinity map. When a problem is not easily identified, using an affinity map can help organize and visually represent different ideas or information related to the issue. This method allows for clustering similar themes or concepts, leading to a clearer understanding of the problem. A: Trial and error involves randomly trying different solutions without a systematic approach. B: The Delphi method is a structured communication technique for gathering opinions from experts, which may not directly help in identifying the problem. C: Political decision-making model focuses on power dynamics and interests, which may not be relevant for problem identification. In summary, using an affinity map promotes structured organization of information, making it the most suitable choice for identifying unclear problems.

Correct Answer: A

Rationale: The correct answer is A: The client reports relief of nausea. This is because when an NG tube is correctly placed in the stomach, it can help decompress the stomach and relieve nausea. Choice B is incorrect because pH less than 5 indicates gastric placement, but it does not confirm correct placement. Choice C is incorrect as bowel sounds can be present even if the tube is incorrectly placed. Choice D is incorrect because an x-ray showing the tube above the pylorus only confirms tube position, not necessarily correct placement.

Correct Answer: B

Rationale: The correct answer is B because intrinsic values refer to fundamental principles or beliefs that are essential for sustaining life, such as honesty, integrity, or compassion. These values are inherent to an individual's being and are not dependent on external factors. Choice A is incorrect as intrinsic values are not necessarily abstract ideas. Choices C and D are incorrect as they relate to personal preferences or expectations rather than core values necessary for life sustenance.

Correct Answer: C

Rationale: The correct answer is C: Diagnose the problem. In Lippitt's phases of change, this phase involves key people in data collection to identify the root cause of the issue. Assessing motivation (A) comes before diagnosing the problem, choosing a change agent (B) is about selecting a person to lead the change effort, and maintaining the change (D) occurs after implementation. Diagnosing the problem is crucial as it sets the foundation for developing effective strategies to address the identified issues.

Correct Answer: D

Rationale: The correct answer is D: Physical therapy for stroke rehabilitation. Tertiary prevention focuses on minimizing the impact of an existing disease or condition. Physical therapy for stroke rehabilitation is an example of tertiary prevention because it aims to improve the quality of life and functionality of an individual who has already experienced a stroke. Administering childhood vaccinations (A) is an example of primary prevention to prevent the onset of diseases. Chemotherapy for cancer treatment (B) is an example of secondary prevention to detect and treat existing cancer. Routine screening for hypertension (C) is an example of secondary prevention to identify and manage hypertension before it progresses.

Correct Answer: B

Rationale: The correct answer is B: Deliver a whole continuum of care. Integrated health care systems are designed to provide comprehensive and coordinated care across various settings to meet the diverse needs of patients. This model emphasizes preventive care, primary care, specialty care, and even mental health services to ensure holistic healthcare delivery. A: Deliver selective care only - This is incorrect as integrated health care systems aim to offer a wide range of services beyond selective care. C: Treat patients only in the hospital - This is incorrect as integrated systems provide care across different settings, not just in hospitals. D: Provide care only in the primary care setting - This is incorrect as integrated systems offer care in multiple settings, not limited to primary care.

Correct Answer: A

Rationale: The correct answer is A: Breakdown in communication. The client's complaint about the night shift nursing staff not responding promptly to his call light indicates a lack of effective communication between the client and the staff. This breakdown in communication leads to the client attempting to walk to the bathroom alone, resulting in a fall. Lack of staff (B) or lack of concern (C) are not directly related to the client's fall, as the core issue lies in communication. Breakdown in management (D) could contribute to communication issues, but the immediate cause of the fall is the lack of communication between the client and the nursing staff.