The nurse double-checked Mr. Gary's meds to avoid errors. This is an example of?

Correct Answer: A

Rationale: Double-checking meds is risk management (A) reducing risks, per definition. Assurance (B) standards, literacy (C) understanding, advocacy (D) rights not risk-specific. A fits the nurse's precaution for Mr. Gary, making it correct.

Correct Answer: B

Rationale: When administering a subcutaneous injection, it is important to insert the needle at a 90-degree angle to ensure proper medication delivery into the subcutaneous tissue. This angle helps prevent the medication from being injected too deeply or too superficially, ensuring optimal absorption and therapeutic effect.

Correct Answer: C

Rationale: Breaking the infection chain at the reservoir means targeting where the microorganism naturally lives like mosquitoes for encephalitis. This differs from the pathogen itself, entry portals, or unrelated water storage. Controlling reservoirs, such as vector elimination, stops transmission early, a vital nursing strategy in outbreak prevention discussed in team settings.

Correct Answer: A

Rationale: Increased heart rate pre-surgery is alarm (A) GAS's initial fight-or-flight, per Selye, with adrenaline surge. Resistance (B) adapts, exhaustion (C) depletes, recovery (D) isn't GAS. A fits acute stress onset, making it correct.

Correct Answer: D

Rationale: Flushing the NG tube with water before and after administering medications is essential to prevent clogging of the tube and ensure proper delivery of medication. This practice helps maintain tube patency and decreases the risk of obstruction, which could compromise the client's treatment and nutrition. By flushing the tube, the healthcare provider ensures that the medication is completely delivered and that there are no residual drug particles left in the tube, which could lead to blockages or inconsistent dosing. Therefore, flushing the NG tube is a crucial step in the safe administration of medications to clients receiving enteral feedings.

Correct Answer: B

Rationale: Maslow's hierarchy (1940s) outlines needs physiological to self-actualization but they aren't rigidly sequential e.g., skipping food for a concert. Common needs (air, water), internal stimuli (hunger), and external triggers (stress) hold true. Nursing recognizes this flexibility, prioritizing patient-specific needs over strict order, enhancing individualized care planning.

Correct Answer: D

Rationale: Restlessness and tachycardia during suctioning suggest hypoxia or distress; discontinuing suctioning and monitoring vital signs (D) is the priority to stabilize the client. Notifying the provider (A) or respiratory (B) delays immediate action. Hyperoxygenating and resuctioning (C) risks worsening hypoxia. D is correct. Rationale: Stopping suctioning halts oxygen depletion, allowing recovery, while monitoring guides further intervention, a standard response per airway management protocols. This prevents complications like arrhythmias or desaturation, prioritizing patient safety over premature escalation or repeated procedures in an unstable state.

Correct Answer: C

Rationale: The planning phase of the nursing process culminates in the creation of a nursing care plan, which outlines specific, measurable goals and interventions tailored to the patient's needs. This plan serves as a roadmap for the implementation phase, ensuring care is individualized and goal-directed. The nursing history, collected during assessment, provides background data but isn't the outcome of planning. Nursing notes document ongoing care and observations, occurring throughout the process, not specifically as a planning product. The nursing diagnosis, formulated in the diagnosis phase, identifies problems but precedes planning; it informs the care plan rather than being its outcome. By producing a nursing care plan, the planning phase bridges assessment and action, enabling nurses to address patient needs effectively and evaluate progress, making it the clear and logical result of this critical step in the nursing process.

Correct Answer: B

Rationale: During recovery from massive tissue loss, Imelda needs a high protein, high calorie diet with vitamins A and C (B). Protein supports tissue repair and collagen synthesis, vital for wound healing. High calories provide energy for metabolic demands of recovery. Vitamins A and C enhance epithelialization and collagen formation. Low calorie options (A, D) lack energy for healing, while low protein (C, D) hinders tissue regeneration. This nutrient-rich diet matches the needs of second intention healing, where extensive repair occurs, making B the correct choice.