Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:

Correct Answer: A

Rationale: Correct Answer: A: Cover wound with moist sterile dressing Rationale: 1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing. 2. Moist dressing prevents the wound from drying out and minimizes the risk of infection. 3. The moist environment supports healing by promoting cell growth and preventing tissue damage. 4. It protects the exposed bowel from further injury and contamination. Summary: B: Finding out how this happened is important but not an immediate priority for patient care. C: Placing sterile dry gauze can lead to the wound drying out and hinder healing. D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.

Correct Answer: B

Rationale: The correct answer is B: Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing. This nursing diagnosis takes highest priority for a client with hyperparathyroidism because the client is at risk for skin breakdown due to edema, skin fragility, and poor wound healing caused by the condition. Skin integrity is crucial for preventing infection and promoting overall health. Choice A is incorrect because hyperparathyroidism is not related to thyroid hormone excess, but rather to parathyroid hormone excess. Choice C is incorrect because body image disturbance is not the highest priority compared to the risk of skin breakdown. Choice D is incorrect because hyperparathyroidism typically leads to hypercalcemia and not imbalanced nutrition related to thyroid hormone excess.

Correct Answer: B

Rationale: The correct answer is B: All women over age 40 should have an annual mammogram. The American Cancer Society recommends annual mammograms starting at age 40 for women with an average risk of breast cancer. This is based on evidence showing that regular mammograms starting at age 40 help in early detection and improve outcomes. Choice A is incorrect because the recommended age is 40, not 30. Choice C is incorrect as it focuses only on family history, while screening guidelines are based on overall risk factors. Choice D is incorrect because feeling at risk alone is not a sufficient indication for annual mammograms without considering other risk factors.

Correct Answer: B

Rationale: The correct answer is B because during outcome identification and planning, it is crucial to prioritize problems that require immediate attention to ensure patient safety and well-being. By asking what problems need immediate attention, nurses can focus on addressing urgent issues first. Choice A focuses on data clustering for problem identification, choice C is related to defining characteristics for nursing diagnoses, and choice D pertains to documentation, which are important but not directly related to prioritizing immediate problems.

Correct Answer: C

Rationale: The correct answer is C: To comply with the medication regimen. Teaching the older client with TIA to comply with medication regimen is crucial in preventing further TIAs or strokes. Medications like antiplatelets or anticoagulants are often prescribed to manage TIA. This education empowers the client to actively participate in their own health management. Incorrect choices: A: Not to worry about the symptoms that are part of the normal aging process - This is incorrect as TIA symptoms are not considered a normal part of aging and should not be ignored. B: To admit oneself to a rehabilitation center or a nursing home for rehabilitation - This is incorrect as it is not the primary intervention for managing TIA. D: To observe any changes in the nails and skin - This is incorrect as it is not directly related to managing TIA.