Nurse Roberto is aware that a client who has experienced cardiac arrest is MOST at risk for which of the following imbalances?

Correct Answer: D

Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.

Correct Answer: A

Rationale: Confirmability is the criteria of trustworthiness that refers to the degree to which the findings of a study are based on the data itself and not on the biases, motivations, or interests of the researchers. In this scenario, returning to the participants to confirm the accuracy of the emerged themes is a way to ensure the confirmability of the study findings. By involving the participants in the validation process, the researchers are seeking to verify that the themes identified truly reflect the experiences of the pregnant women in labor as reported by the participants. This practice enhances the credibility and trustworthiness of the study's findings by confirming their alignment with the participants' perspectives and experiences.

Correct Answer: A

Rationale: The purpose of a tracheostomy is to establish an artificial airway in the trachea through a surgical procedure. This is done to bypass obstructions in the upper airway, assist with breathing, or facilitate the removal of secretions from the lungs. A tracheostomy helps in maintaining a clear and secure airway for patients who have difficulty breathing or require long-term mechanical ventilation support.

Correct Answer: A

Rationale: Checking the flow of oxygen is the priority action because it ensures that Sonny is receiving the correct amount of oxygen prescribed by the healthcare provider. Before connecting the flow meter to the oxygen outlet, turning on the oxygen, or attaching the humidifier, it is crucial to verify that the flow rate is appropriate for Sonny's condition. Monitoring and adjusting the oxygen flow will help maintain the desired oxygen saturation levels and prevent potential complications related to oxygen therapy.

Correct Answer: D

Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.

Correct Answer: B

Rationale: Assisting the client to a seated position on the toilet should be implemented first. This position promotes relaxation of the pelvic floor muscles and can help facilitate urinary elimination. It is a non-invasive and least intrusive intervention compared to performing intermittent catheterization or administering diuretic medication. Encouraging the client to drink plenty of fluids is important for promoting overall urinary function, but in this case, the priority is to aid the client in attempting to void first.

Correct Answer: B

Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.

Correct Answer: C

Rationale: Introducing solid food to a three-month-old baby is considered a poor healthcare attitude as it goes against the recommended guidelines for infant feeding. The World Health Organization (WHO) and other health authorities suggest exclusive breastfeeding for the first six months of a baby's life, followed by the introduction of safe and appropriate complementary foods. Introducing solid food too early can increase the risk of food allergies, obesity, and other health issues in babies. Therefore, a young mother introducing solid food to her three-month-old baby is evidence of a poor family coping index related to healthcare attitudes.

Correct Answer: B

Rationale: Administering ice packs to the perineum is the priority nursing intervention to provide relief for perineal pain and discomfort in a postpartum client. Ice packs help to reduce swelling and inflammation in the perineal area, which can help alleviate pain. It is a safe and effective method to provide immediate relief and promote comfort for the client. Other interventions such as encouraging ambulation, administering analgesics, and recommending warm sitz baths can also be beneficial, but in the initial management of perineal pain, ice packs are the most appropriate choice.