The nurse is developing a plan of care for a client. Which nursing action is defined as an activity(ies)/intervention(s)?

Correct Answer: A

Rationale: Nursing interventions encompass a broad spectrum of actions aimed at meeting client needs, reflecting the profession's holistic approach. Holding the client's hand is a simple yet profound intervention that provides emotional support, comfort, and reassurance, addressing psychological well-being alongside physical care. Starting an IV is a technical procedure that delivers fluids or medications, directly impacting physiologic health. Educating clients empowers them with knowledge about their condition or self-care, fostering autonomy and health maintenance. However, diagnosing a medical condition falls outside nursing's scope, as it's a physician's responsibility to identify diseases based on clinical findings. Nurses assess, plan, and implement care based on those diagnoses, not make them. These interventions highlight nursing's diverse role from hands-on procedures to supportive gestures each tailored to improve client outcomes across physical, emotional, and educational dimensions, aligning with the profession's caring ethos.

Correct Answer: C

Rationale: Arranging dental education for children targets health promotion, enhancing well-being through lifestyle choices like proper brushing to prevent cavities. This proactive step builds health habits, aligning with nursing's aim to protect and improve health before illness strikes, distinct from preventing specific diseases (illness prevention). High-level wellness seeks maximal potential, broader than this focused event. Reversal of self-care deficits involves therapeutic fixes, not education. Health promotion here empowers kids with skills brushing technique to maintain oral health, reducing future dental issues. It's primary prevention in action, leveraging community teaching to instill lifelong practices, a core nursing strategy for population health that prioritizes empowerment over reaction.

Correct Answer: C

Rationale: Teaching a diabetic client daily foot inspections is tertiary prevention, managing an existing condition to prevent complications like ulcers or amputations. Diabetes is chronic, and this intervention post-diagnosis focuses on reducing further harm by catching skin issues early, a common risk due to neuropathy. Primary prevention, like diet to avoid diabetes, precedes onset. Secondary prevention screens for initial signs, not ongoing care. 'Chronic' isn't a level. Nursing's tertiary role here empowers self-monitoring, critical since poor circulation masks injuries studies show inspections slash amputation rates. This aligns with chronic disease management, ensuring the client maintains function and avoids escalation, reflecting nursing's emphasis on practical, preventive care within an established illness.

Correct Answer: C

Rationale: Without specific notes, the priority action hinges on common critical scenarios. Having the defibrillator ready at the bedside (C) is the most urgent action if the notes suggest cardiac instability (e.g., arrhythmias), as defibrillation addresses life-threatening ventricular rhythms per ACLS protocols. Ensuring endotracheal intubation readiness (A) is vital for airway compromise, but respiratory decline typically progresses slower than cardiac arrest. Preparing protamine sulfate (B) reverses heparin in bleeding, but this is less immediate unless hemorrhage is explicit. Sugammadex (D) reverses neuromuscular blockers, relevant post-surgery, not broadly urgent. C is selected as the priority due to its alignment with rapid life-saving intervention. Rationale: Cardiac arrest is a leading cause of death in critical care; a defibrillator's immediate availability can restore rhythm within minutes, critical when notes imply deteriorating vitals, outweighing preparatory actions like intubation or drug administration in urgency and impact.

Correct Answer: C

Rationale: Without a figure, nasotracheal suctioning typically requires a semi-Fowler's position (30-45° head elevation), assumed as Position 3 (C), to align the airway and reduce aspiration risk. Flat (A), high Fowler's (B), or prone (D) are less optimal. C is correct. Rationale: Semi-Fowler's facilitates catheter passage and secretion drainage, minimizing complications like gagging or hypoxia, a standard positioning per respiratory care protocols.