The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing and the type of drainage present, then will progress to more specific assessments based on the findings. This approach allows for a systematic and comprehensive evaluation of the patient's condition by moving from general observations to detailed examinations. Explanation: 1. General assessment: The nurse is initially assessing the overall appearance of the surgical dressing and the type of drainage. 2. Specific assessment: Based on the initial findings, the nurse will proceed to conduct more focused assessments, such as checking for signs of infection, monitoring vital signs, and assessing the surgical site for any complications. Other choices are incorrect: A: Gordon’s Functional Health Patterns - This framework focuses on assessing different aspects of an individual's health patterns, such as activity level, sleep patterns, and coping mechanisms. It is not the most appropriate approach in this situation. B: Activity-exercise pattern assessment - This type of assessment focuses

Correct Answer: C

Rationale: The correct answer is C: Avoiding the use of carbonated beverages. Carbonated beverages often have high sodium content, which can contribute to increased sodium intake. By avoiding these beverages, the client can significantly reduce their sodium consumption. Explanation: 1. Carbonated beverages often contain added sodium for flavor enhancement. 2. By avoiding carbonated beverages, the client eliminates a significant source of hidden sodium in their diet. 3. This dietary practice directly targets reducing sodium intake without compromising other nutritional aspects of the diet. Summary of other choices: A: Increasing the use of dairy products - Dairy products do not necessarily impact sodium intake significantly. B: Using an artificial sweetener in coffee - Artificial sweeteners do not contribute to sodium intake. D: Using catsup for cooking and flavoring food - Catsup is high in sodium and would not help in reducing sodium intake.

Correct Answer: D

Rationale: The correct answer is D: fractures. Osteoporosis weakens bones, making them more prone to fractures. Fractures are the primary complication of osteoporosis due to decreased bone density. Increased trabeculae (A) is incorrect as osteoporosis leads to decreased bone density, not increased. Poor posture (B) may be a result of osteoporosis but is not its primary complication. Chronic pain (C) can occur with osteoporosis but is not as directly linked as fractures.

Correct Answer: C

Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.

Correct Answer: D

Rationale: The correct answer is D: A painless mass in the breast. This is the primary sign of breast cancer because most breast cancers present as painless lumps or masses. This is due to the abnormal growth of cells forming a tumor. Other choices (A, B, C) are also signs of breast cancer, but they are not as common or primary as the presence of a painless mass. A bloody discharge from the nipple (A) can be a sign of a benign condition or cancer, but it is not the most common presentation. Nipple retraction (B) and dimpling of the skin over the lesion (C) can also be signs of breast cancer, but they usually occur in later stages of the disease. Therefore, the presence of a painless mass in the breast is the primary sign that should raise suspicion for breast cancer.

Correct Answer: A

Rationale: The correct answer is A because evaluating a nursing intervention involves collecting data to determine if the goals set for the intervention were achieved. This process helps in assessing the effectiveness of the intervention in meeting the desired outcomes. Option B is incorrect as it refers to the identification of nursing diagnoses for new problems, which is part of the nursing assessment phase, not evaluation. Option C is incorrect as adjusting the care plan to include collaborative interventions is part of the implementation phase, not evaluation. Option D is incorrect as performing client care tasks as per protocol is part of the implementation phase, not evaluation.

Correct Answer: B

Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.

Correct Answer: B

Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. Rationale: During a spinal block, the anesthesiologist injects anesthesia into the subarachnoid space, which contains CSF. Proper positioning ensures that the anesthesia stays in place and prevents leakage of CSF, which could lead to complications such as post-dural puncture headache. Incorrect choices: A: To prevent confusion - Irrelevant to the procedure. C: To prevent seizures leakage - Seizures are not a concern with spinal blocks. D: To prevent cardiac arrhythmias - Cardiac arrhythmias are not directly related to spinal blocks.

Correct Answer: C

Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed. A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure. B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis. D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.