An adult has and IV line in the right forearm infusing D5 ½ NS with 20 mEq of potassium at 75 ml/h. which statement would be a correct report from the RN?

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Potassium is typically administered on a secondary line to prevent rapid infusion and potential adverse effects. 2. The primary line carries the D5 ½ NS solution without potassium, while the secondary line delivers the potassium. 3. Reporting that "potassium is on the secondary line" accurately describes the setup for this IV infusion. Summary: A: Incorrect - Incorrectly states that the potassium bag is piggybacked into the dextrose. B: Incorrect - Closing the clamp below the D5 ½ NS bag is unnecessary and does not address the potassium infusion. D: Incorrect - Fails to address the specific issue of the potassium infusion being on a secondary line.

Correct Answer: C

Rationale: The correct answer is C because performing a physical examination is the method nurses use to establish a patient's database. This involves directly assessing the patient's physical condition, gathering data on their health status, and identifying any abnormalities or concerns. Reviewing literature (A) is important but not a direct method of collecting patient data. Checking orders for tests (B) is part of data collection but not the initial step. Ordering medications (D) is a treatment action, not data collection.

Correct Answer: D

Rationale: The correct answer is D: Aphasia. Mr. Dela Isla's inability to comprehend what the nurse was saying indicates a language impairment, which is characteristic of aphasia. Aphasia is a condition that affects a person's ability to understand or produce language due to damage to the brain's language centers. Insomnia (A) is a sleep disorder, Agnosia (B) is a perception disorder, and Apraxia (C) is a motor planning disorder, none of which align with Mr. Dela Isla's symptoms.

Correct Answer: D

Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life. A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging. B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions. C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.

Correct Answer: B

Rationale: Step 1: Crowded living conditions do not directly increase the risk of lung cancer. Step 2: Passive smoke (choice A) and air pollution (choice C) contain carcinogens linked to lung cancer. Step 3: Diet low in fruits and vegetables (choice D) may lead to poor immune function, potentially impacting cancer risk. Step 4: In summary, crowded living conditions do not contribute to lung cancer risk compared to the other choices.

Correct Answer: A

Rationale: The correct answer is A. 1. Change in level of consciousness is crucial in assessing neurological status. 2. Tachypnea indicates possible respiratory distress or oxygenation issues. 3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion. 4. Petechiae can be a sign of bleeding disorders or sepsis. Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms. Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E. Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. This involves analyzing assessment data, utilizing critical thinking skills to identify patient problems, and formulating nursing diagnoses. Diagnostic reasoning is the process of synthesizing information to make clinical judgments and determine appropriate interventions. A: Assigning clinical cues - Incorrect. This refers to identifying observable signs or symptoms, not the process of developing a nursing diagnosis. B: Defining characteristics - Incorrect. This term is often used to describe the symptoms or manifestations associated with a nursing diagnosis, not the process of deriving the diagnosis. D: Diagnostic labeling - Incorrect. This is the final step in the nursing diagnosis process where the nurse assigns a label to the identified patient problem, not the process of critical thinking and data analysis.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, skin condition, and overall health status. It provides a comprehensive overview of the patient's current health status and helps in establishing a baseline for further assessments and interventions. Reviewing literature (A) is important for evidence-based practice but does not directly establish a patient's database. Checking orders for tests (B) is essential but does not provide a holistic view of the patient. Ordering medications (D) is a treatment intervention and not a data collection method.

Correct Answer: B

Rationale: The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection. Summary: A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure. C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention. D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.