The interpretation of the data collected about the patient represents the

Correct Answer: A

Rationale: Assessment in the nursing process involves collecting and interpreting data (e.g., vitals, symptoms) to identify patient status. Health problems emerge from this analysis, forming diagnoses. The care plan and interventions follow, based on assessment findings. Nurses rely on this step to establish a baseline, ensuring accurate diagnoses and tailored care, foundational to effective patient management across all settings.

Correct Answer: A

Rationale: Placing the feeding 20 inches above the nasogastric tube's insertion point is inappropriate, as excessive height causes rapid flow, risking aspiration or gastric distension. Standard practice recommends 12-18 inches for controlled delivery, ensuring patient safety and comfort. Introducing the feeding slowly prevents sudden stomach overload, reducing nausea or reflux correct practice. Instilling 60 ml of water post-feeding clears the tube, maintaining patency and hydration a standard, appropriate step. Assisting the patient into Fowler's position (elevated head) minimizes aspiration risk, aligning with best practice. The excessive height deviates from guidelines, potentially overwhelming the stomach's capacity and compromising digestion or respiratory safety, making it the clear inappropriate action in NGT feeding administration.

Correct Answer: B

Rationale: Critical thinking during assessment enables the nurse to direct it meaningfully and purposefully, analyzing data as it's gathered to focus on relevant areas e.g., probing shortness of breath to uncover asthma triggers. This ensures efficiency and relevance, avoiding aimless data collection. Reviewing with providers happens post-assessment, not during, and isn't its direction. Determining care delivered is planning/implementation, not assessment's role, which collects data first. Identifying anticipated responses aligns with evaluation, not the initial data-gathering phase. Critical thinking sharpens assessment's focus, prioritizing key findings (e.g., abnormal vitals), making it purposeful and driving subsequent care decisions effectively, a hallmark of skilled nursing practice.

Correct Answer: D

Rationale: A nurse wears a gown primarily when the patient's blood or body fluids may contaminate their clothing, adhering to standard precautions for infection control. This protects against pathogens e.g., during wound care or childbirth reducing transmission risk. Poor hygiene might prompt gloves or masks, but gowns target fluid exposure, not general cleanliness. Medication administration rarely involves fluid splash unless invasive (e.g., IV), not routine enough for gowns. AIDS alone doesn't mandate gowns unless fluid exposure is likely precautions are universal, not disease-specific. Fluid contact is the key trigger, as per CDC guidelines, ensuring nurse safety and preventing cross-contamination, making this the most precise scenario for gown use in clinical practice.

Correct Answer: B

Rationale: Side-lying prevents aspiration in an unconscious client during mouth care.