As a strong believer of her faith and the need for spiritual guidance, patient Ximena requests that she wants that clergy will visit her. How did nurse Parker function when she initiated the visit?

Correct Answer: D

Rationale: Nurse Parker functioned independently when she initiated the visit by arranging for the clergy to see patient Ximena. In this scenario, the nurse took the initiative on her own without needing approval or direction from others. She recognized the patient's request for spiritual guidance and took independent action to meet that need. Independently functioning in this context demonstrates the nurse's autonomy and ability to make decisions based on the patient's preferences and well-being.

Correct Answer: D

Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.

Correct Answer: B

Rationale: Total care nursing is a nursing care delivery model where one nurse is assigned to provide comprehensive care to a patient for an entire shift. In this case, the private duty nurse is providing holistic care to the post-caesarian patient during the shift, which aligns with the principles of total care nursing. This approach allows the nurse to focus on the individual needs of the patient and provide all aspects of care, promoting continuity and personalized attention. Total care nursing ensures that the patient receives consistent and dedicated care from the same nurse, enhancing the patient's overall experience and outcomes.

Correct Answer: D

Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.

Correct Answer: A

Rationale: A nursing assistant can be delegated the task of changing wound dressings because it is considered a basic nursing care activity that does not require specialized training or knowledge. Nursing assistants are trained to perform tasks related to personal care, hygiene, and basic wound care under the supervision of a registered nurse. Changing wound dressings is a routine nursing task that can be safely delegated to a nursing assistant, allowing the nurse to focus on other aspects of patient care that require specialized nursing skills and knowledge.