A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?

Correct Answer: A

Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue. Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.

Correct Answer: B

Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan. A: Documenting interventions is important but not the primary focus during the evaluation phase. C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan. D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.

Correct Answer: B

Rationale: The correct answer is B: Monitor temperature every 4hrs. This is crucial in detecting signs of urinary tract infection as fever is a common symptom. Monitoring temperature regularly allows for early detection and appropriate intervention. A: Encouraging the client to breathe deeply and cough every 2hrs is a measure to prevent respiratory complications postoperatively, not related to UTI detection. C: Splinting the incision when repositioning the client is important for wound care, not for detecting UTI. D: Irrigating tubes as ordered is a specific intervention for tube care, not for monitoring UTI symptoms.

Correct Answer: A

Rationale: The correct action is to report the ulcer to the admitting care provider first. This is essential because the ulcer could be a sign of an underlying infection or condition that needs immediate attention, especially in a hospitalized patient with pneumonia. Reporting the ulcer ensures prompt evaluation and appropriate treatment. The other options are incorrect because teaching about STD prevention and asking about syphilis assume the cause of the ulcer is related to a sexually transmitted infection, which may not be the case in this scenario. Additionally, cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can lead to complications or delay in appropriate treatment.

Correct Answer: A

Rationale: The correct answer is A: Fruits such as bananas. Bananas are high in potassium, which is essential for various bodily functions like muscle contractions and maintaining fluid balance. Fruits are a natural source of potassium and are easily incorporated into the diet. Milk and yogurt (B) are good sources of calcium, not potassium. Green leafy vegetables (C) are nutritious but may not provide as much potassium as fruits. Nuts and legumes (D) are good sources of protein and healthy fats but are not as rich in potassium as fruits like bananas.