In planning for Jose's oxygen therapy, the nurse shall consider which of the following, EXCEPT

Correct Answer: C

Rationale: When planning for Jose's oxygen therapy, the nurse should consider the need for a humidifier to prevent drying of the mucous membranes, the appropriate length of tubing for mobility and safety reasons, and the manner of administering oxygen (continuous or intermittent) based on Jose's condition and oxygen requirements. However, determining Jose's age is not a relevant factor in planning for his oxygen therapy. The decision-making process should be based on his specific medical needs and condition rather than his age.

Correct Answer: B

Rationale: When a patient receiving palliative care for end-stage COPD expresses a desire to discuss advance care planning, the palliative nurse should initiate a conversation about advance directives and future care preferences. Advance care planning involves discussing and documenting a patient's preferences regarding future medical care, particularly in situations where the patient may no longer be able to make decisions. This discussion helps ensure that the patient's wishes are respected and followed in the event they are unable to communicate their preferences. By engaging in advance care planning discussions, the nurse can help the patient feel empowered, supported, and in control of their medical care decisions. It also allows healthcare providers to align care with the patient's values and goals, ultimately improving quality of life and ensuring dignity at the end of life.

Correct Answer: A

Rationale: It is important for the nurse to provide the PACU nurse with the patient's intraoperative vital signs and hemodynamic parameters as this information gives insight into the patient's stability during the surgical procedure. The PACU nurse needs this data to monitor the patient's postoperative recovery, assess for any potential complications, and establish appropriate care interventions. Understanding the patient's intraoperative status allows the PACU nurse to provide a seamless continuation of care from the operating room to the post-anesthesia care unit. The details of the surgical procedure and anesthesia administration are also important but are typically conveyed through the surgical and anesthesia records. The plan for postoperative pain management and analgesic medications is essential but can be discussed and adjusted based on the patient's current status in the PACU. Documentation of the surgical count and instrument inventory is crucial for ensuring patient safety but is typically managed by the operating room team and may not be the immediate

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.

Correct Answer: A

Rationale: Myxedema is a severe form of hypothyroidism that is characterized by the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues. This condition leads to puffiness, swelling, and thickening of the skin, giving it a waxy appearance. Other symptoms of myxedema include fatigue, weight gain, cold intolerance, and hair loss. It is important to recognize and treat myxedema promptly as it can lead to serious complications such as myxedema coma, which is a life-threatening condition requiring immediate medical attention.

Correct Answer: D

Rationale: A trimalleolar fracture is characterized by fractures involving the lateral malleolus (distal fibula), medial malleolus (distal tibia), and the posterior tubercle of the distal tibia. This fracture pattern results in instability of the ankle joint and is often associated with widening of the ankle mortise on X-ray. The deformity and swelling seen in this patient are indicative of a trimalleolar fracture and are typically caused by a high-energy injury, such as a forceful twisting motion. Treatment for trimalleolar fractures often involves surgical intervention to stabilize the ankle joint and restore normal function.

Correct Answer: A

Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.

Correct Answer: A

Rationale: Flexibility is the most important criterion in budgeting because it allows for adjustments to be made as circumstances change. Budgeting is a dynamic process, and having a flexible budget enables organizations or individuals to adapt to unexpected changes in income or expenses. This helps in ensuring that resources are allocated efficiently and effectively to meet the overall financial goals. Consistency, standardization, and cost-effectiveness are also important considerations in budgeting, but flexibility is key to successfully managing financial resources in a changing environment.

Correct Answer: C

Rationale: The primary purpose of conducting an audit in a health facility is to ensure that standards are met. Audits are conducted to review and evaluate the documentation and practices within a healthcare facility to ensure compliance with established standards, protocols, procedures, and regulations. By conducting audits, the facility can identify any discrepancies, non-compliance with standards, or areas for improvement to maintain high-quality care and patient safety. This process helps in maintaining a high standard of care, reducing errors, promoting quality improvement initiatives, and ensuring the overall efficiency and effectiveness of healthcare services provided in the facility.