Before administering a food feeding the nurse knows to perform which of the following assessments/

Correct Answer: A

Rationale: The correct answer is A because assessing the GI tract is crucial before feeding to ensure proper digestion and absorption. Bowel sounds, last BM, and distention indicate GI function. The client's neurologic status and gag reflex are important to prevent aspiration. Option B is not a primary concern before feeding. Option C is incorrect as formula should be warmed to room temperature before feeding.

Correct Answer: C

Rationale: The correct answer is C because the food pyramid suggests daily food choices based on the different food groups. It provides a visual guide on the proportions of each food group to consume for a balanced diet. It does not specify the exact number of servings (A), calculate calories (B), or divide food into four basic groups (D). The food pyramid is a tool to help individuals make healthier food choices by emphasizing variety and moderation.

Correct Answer: B

Rationale: Correct Answer: B (State Nurse Practice Acts) Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care. Summary of Incorrect Choices: A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice. C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice. D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.

Correct Answer: A

Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.

Correct Answer: A

Rationale: The correct answer is A: once a month after menstruation. Performing BSE at this time helps ensure consistent examination when breasts are less tender or swollen, making it easier to detect abnormalities. Performing it once a month ensures regular monitoring for any changes. Choices B, C, and D are incorrect because they do not provide the recommended frequency or timing for an effective BSE. BSE should be done monthly after menstruation to increase the chances of early detection of breast cancer.

Correct Answer: C

Rationale: Objective data are measurable and observable facts. Respirations (C) of 16 per minute is objective data as it is a quantifiable measurement that can be counted and recorded. It is not influenced by personal interpretation or bias. Choices A, B, and D are subjective data as they rely on the patient's feelings, perceptions, or symptoms, which can vary and are open to interpretation. Therefore, choice C is the correct answer as it represents concrete, verifiable information that can be used in the patient's assessment and care planning.

Correct Answer: A

Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows: 1. The patient has a standing order for acetaminjson for headache relief. 2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours. 3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs. Summary: - Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order. - Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision. - Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.

Correct Answer: C

Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately. Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed. Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms. Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement. In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.

Correct Answer: A

Rationale: The correct answer is A: Weight. Monitoring daily weight is crucial in assessing fluid retention and worsening heart failure symptoms. Weight gain can indicate fluid overload, a common complication in heart failure. The other choices (B: Appetite, C: Calorie count, and D: Abdominal girth) are not as directly related to monitoring heart failure severity. Appetite and calorie count may be affected by various factors unrelated to heart failure, while abdominal girth may not provide specific information on fluid status. Monitoring weight allows for early intervention and adjustments in treatment to prevent exacerbation of heart failure symptoms.