A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to

Correct Answer: A

Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.

Correct Answer: C

Rationale: The correct answer is C because crushing or breaking tablets can alter the medication's effectiveness or cause harm. Step 1: Consult a physician or pharmacist ensures safety and effectiveness. Step 2: This step helps in determining if the medication can be safely altered for easier swallowing. Step 3: Using liquid form (B) may not always be an option. Mixing with food (A) can affect absorption. ROM exercises (D) are unrelated to medication administration.

Correct Answer: D

Rationale: The correct answer is D, the elderly patient receiving a diuretic for fluid overload. This patient would benefit most from a capped IV catheter used intermittently because diuretics can lead to fluctuations in fluid balance that require careful monitoring and adjustment of IV fluids. By using the catheter intermittently, healthcare providers can better control the amount of fluid administered to prevent electrolyte imbalances. Option A is incorrect because a patient with pneumonia requiring fluids and antibiotics would likely benefit from a continuous IV to maintain stable levels of medications and hydration. Option B is incorrect as a patient with major blood loss would require continuous IV fluids to restore blood volume. Option C is incorrect as a dehydrated young child would also benefit from continuous IV fluids to rehydrate effectively.

Correct Answer: B

Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.

Correct Answer: B

Rationale: The correct answer is B: Sleeps for a period of time. After a seizure, the brain and body experience fatigue and exhaustion. It is common for the patient to feel drowsy and require rest to recover. This post-ictal state is characterized by sleepiness and confusion. The other choices are incorrect because typically, after a seizure, the patient is not most comfortable walking and moving about (A), does not become restless and agitated (C), and may not immediately express thirst and hunger (D). It is important to ensure the patient is in a safe environment and allow them to rest after a seizure episode.

Correct Answer: B

Rationale: The correct answer is B because conducting the interview in a quiet environment, such as the waiting area with the television turned off, minimizes background noise and distractions for a patient with a hearing deficit. This setting allows for better communication and ensures that the patient can hear and understand the nurse clearly. A: Conducting the interview in the patient's room with the door closed may still have background noise from the hallway or other rooms. C: Conducting the interview before administration of pain medication is not relevant to improving communication for a patient with a hearing deficit. D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional noise and distractions, making it difficult for the patient to focus on the conversation.

Correct Answer: C

Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections. Now, let's analyze the other choices: A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy. B: Sleep in a semi-fowler’s position - Positioning does not directly impact infection prevention post-splenectomy. D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.

Correct Answer: C

Rationale: The correct answer is C: A 6-hour glucose tolerance test. This test involves measuring blood glucose levels at specific intervals after consuming a glucose solution, providing a comprehensive assessment of glucose utilization over time. This test is particularly useful in evaluating how the body processes glucose after a meal and can help diagnose conditions such as diabetes. A: A fasting blood glucose test would not provide a comprehensive picture of glucose utilization over time since it only measures glucose levels in a fasted state. B: A test of serum glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past 2-3 months but does not directly assess glucose utilization after a meal. D: A test for urine ketones is used to detect ketones in the urine, which can indicate diabetic ketoacidosis but does not directly measure glucose utilization.

Correct Answer: C

Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration. Summary: A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications. B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue. D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.