A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?

Correct Answer:

Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly. Rationale: 1. This choice outlines a specific nursing intervention - ambulating with crutches. 2. It includes clear actions for the patient to ambulate and specifies using crutches correctly. 3. It addresses the patient's physical mobility needs actively. 4. It focuses on promoting independence and functional ability. Summary of other choices: B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer. C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation. D: This choice only identifies the patient's condition without providing a specific nursing intervention.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is using assessment data to analyze, interpret, and make a judgement about the patient's condition. This process involves critical thinking skills to develop a nursing diagnosis. Choice A (Assigning clinical cues) is incorrect because it refers to identifying specific signs and symptoms. Choice B (Defining characteristics) is incorrect as it pertains to the features of a diagnosed condition. Choice D (Diagnostic labeling) is incorrect because it focuses on naming a specific nursing diagnosis. Diagnostic reasoning encompasses the entire process of analyzing data, making connections, and formulating a nursing diagnosis based on critical thinking.

Correct Answer: D

Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.

Correct Answer: C

Rationale: The correct answer is C: 2, 3, and 4. High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for developing hypertension. High cholesterol can lead to atherosclerosis, increasing blood pressure. Smoking can constrict blood vessels, raising blood pressure. Sedentary lifestyle can lead to obesity and overall poor cardiovascular health, contributing to hypertension. Race and age are non-modifiable risk factors. Choice A is incorrect because it includes race, a non-modifiable factor. Choice B is incorrect because it includes age, which is also non-modifiable. Choice D is incorrect because it includes all factors, including non-modifiable ones.

Correct Answer: B

Rationale: The correct answer is B: Potato. Potatoes are high in potassium, which is essential for various bodily functions. Potatoes can help increase potassium intake in patients who require it. Bread, eggs, and cereal are not as rich in potassium as potatoes. Increasing intake of these foods won't provide the necessary boost in potassium levels needed for the patient.

Correct Answer: A

Rationale: Rationale: The correct answer is A, overstimulation of the parathyroid hormone. After a thyroidectomy, there is a risk of unintentional damage to the parathyroid glands, leading to hypoparathyroidism. Circumoral tingling, positive Chvostek’s sign, and positive Trousseau’s sign are classic signs of hypocalcemia resulting from parathyroid insufficiency. Choices B, C, and D are incorrect because they do not explain the specific symptoms observed in Emil, which are indicative of low calcium levels due to parathyroid dysfunction.

Correct Answer: D

Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.

Correct Answer: B

Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes. A: Taking medication with meals is not necessary for rifampin administration. C: Avoiding wearing glasses is not relevant to rifampin treatment. D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.

Correct Answer:

Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly. Rationale: 1. This choice outlines a specific nursing intervention - ambulating with crutches. 2. It includes clear actions for the patient to ambulate and specifies using crutches correctly. 3. It addresses the patient's physical mobility needs actively. 4. It focuses on promoting independence and functional ability. Summary of other choices: B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer. C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation. D: This choice only identifies the patient's condition without providing a specific nursing intervention.