If a Wall unit is used, What should be the suctioning pressure required by James?

Correct Answer: C

Rationale: Step 1: The optimal suctioning pressure for adults is usually between 80-120 mmHg. Step 2: Choice C falls within this recommended range (95-110 mmHg). Step 3: Higher pressures (like in choices B and D) can cause tissue damage. Step 4: Lower pressures (like in choice A) may not effectively remove secretions. Summary: Choice C (95-110 mmHg) is correct as it falls within the safe and effective suctioning pressure range for adults, while the other choices are either too high or too low, risking harm or inefficiency.

Correct Answer: A

Rationale: The correct answer is A because it is specific, measurable, achievable, relevant, and time-bound (SMART) - the patient verbalizing a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. This outcome is immediate, concrete, and directly related to the goal of managing pain. Choice B is incorrect as it lacks specificity and a clear timeframe for evaluation. Choice C is incorrect because the outcome is vague and does not specify when the patient needs to understand the dietary changes. Choice D is incorrect because the timeframe is provided but the outcome is not specific enough and does not directly relate to the goal of pain management.

Correct Answer: A

Rationale: The correct answer is A: Postural hypotension. This condition is characterized by a drop in blood pressure upon standing, leading to dizziness. The client's symptoms of dizziness upon standing, along with nosebleeds and blurred vision, are indicative of low blood pressure. Postural hypertension (B) is not a recognized medical condition; White coat hypertension (C) refers to elevated blood pressure readings in a medical setting due to anxiety; White coat hypotension (D) is not a recognized medical condition.

Correct Answer: A

Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action. Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.

Correct Answer: B

Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.

Correct Answer: D

Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.

Correct Answer: E

Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include: E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively. Incorrect choices: A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder. B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder. C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder. D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is using assessment data to analyze, interpret, and make a judgement about the patient's condition. This process involves critical thinking skills to develop a nursing diagnosis. Choice A (Assigning clinical cues) is incorrect because it refers to identifying specific signs and symptoms. Choice B (Defining characteristics) is incorrect as it pertains to the features of a diagnosed condition. Choice D (Diagnostic labeling) is incorrect because it focuses on naming a specific nursing diagnosis. Diagnostic reasoning encompasses the entire process of analyzing data, making connections, and formulating a nursing diagnosis based on critical thinking.

Correct Answer: C

Rationale: Step 1: The optimal suctioning pressure for adults is usually between 80-120 mmHg. Step 2: Choice C falls within this recommended range (95-110 mmHg). Step 3: Higher pressures (like in choices B and D) can cause tissue damage. Step 4: Lower pressures (like in choice A) may not effectively remove secretions. Summary: Choice C (95-110 mmHg) is correct as it falls within the safe and effective suctioning pressure range for adults, while the other choices are either too high or too low, risking harm or inefficiency.