In planning for Sonny's oxygen therapy, the nurse should consider which of the following, EXCEPT

Correct Answer: C

Rationale: The nurse does not need to determine the age of Excel when planning for Sonny's oxygen therapy. This information is irrelevant to the specific care requirements of Sonny's oxygen therapy. Sonny's age, medical history, respiratory status, and oxygen needs are the key considerations in planning for his oxygen therapy. The nurse should focus on factors such as the need for a humidifier, length of tubing, and the manner of administering oxygen (continuous or intermittent) to ensure effective and safe delivery of oxygen therapy to Sonny.

Correct Answer: B

Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.

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: B

Rationale: The assessment of a patient who has ingested poison must include determining the poison ingested and the amount (I), the time from ingestion and the signs and symptoms (II), as well as the weight of the patient (III). These factors are essential in evaluating the severity of the poisoning and determining the appropriate treatment plan. However, the patient's immunization history (IV) is not directly relevant to the assessment of ingested poison and thus is not essential in this context.

Correct Answer: A

Rationale: The initial treatment goal for a patient like Mila is often focused on preventing infection. Infection prevention is a basic and essential step in patient care, especially for someone who may be at risk due to their medical condition or treatment plan. By preventing infection, healthcare providers can help ensure the patient's safety and promote successful outcomes for the overall treatment plan. Correcting hypoxia, metabolic acidosis, and increasing myocardial oxygen supply may be important goals as well, but preventing infection is usually prioritized as it can have serious consequences if not addressed promptly.

Correct Answer: C

Rationale: The central theme of Sr. Callista Roy's theory is adaptation. Roy's Adaptation Model focuses on the individual's ability to adapt to internal and external stimuli in order to maintain health and well-being. The theory emphasizes the interconnectedness of the individual and their environment, highlighting the dynamic process of adaptation in response to stimuli. By focusing on adaptation, Roy's theory guides nursing practice in promoting holistic care that supports individuals in adapting to changes and achieving optimal health outcomes.

Correct Answer: D

Rationale: The causative agent of dengue fever is a virus. Dengue fever is primarily transmitted to humans by the bite of infected Aedes mosquitoes, particularly Aedes aegypti and Aedes albopictus. These mosquitoes act as vectors, carrying and transmitting the dengue virus (specifically four closely related but antigenically different serotypes: DEN-1, DEN-2, DEN-3, and DEN-4) to humans during the feeding process. The virus then replicates in the human body, causing symptoms of dengue fever. Therefore, the correct answer is D. Virus.

Correct Answer: C

Rationale: The patient's presentation of swelling of the ankles, dyspnea on exertion, and orthopnea is highly suggestive of heart failure. The echocardiogram findings of decreased left ventricular ejection fraction and dilated left ventricle are characteristic of heart failure with reduced ejection fraction (HFrEF), also known as systolic heart failure. In this condition, the heart's ability to pump blood effectively is compromised, leading to symptoms of congestion and decreased cardiac output. The decreased ejection fraction indicates that the heart is not able to efficiently pump out blood with each contraction. Dilatation of the left ventricle is a compensatory mechanism in response to increased volume overload.

Correct Answer: A

Rationale: In a patient with severe abdominal pain due to end-stage pancreatic cancer, the priority intervention to manage their symptoms would be to provide adequate pain relief. Opioid analgesics are the cornerstone of pain management for cancer patients experiencing severe pain. They work by binding to opioid receptors in the central nervous system, thereby reducing the perception of pain. Opioids are highly effective in managing cancer pain, including abdominal pain, and can significantly improve the patient's quality of life by providing relief from distressing symptoms. Therefore, administering opioid analgesics should be the nurse's primary intervention in this case to address the patient's severe abdominal pain. Initiating enteral nutrition, recommending hot compresses, or referring to a gastroenterologist may be relevant interventions depending on the patient's overall care plan but addressing the pain should be the immediate priority in this scenario.