The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

Correct Answer: A

Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection. Summary of why other choices are incorrect: B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection. C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections. D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.

Correct Answer: A

Rationale: The correct answer is A: Anticholinesterase drugs. These drugs increase acetylcholine levels at neuromuscular junctions, helping improve muscle strength in myasthenia gravis. Adrenergic drugs (B) and beta-blocker drugs (D) are not typically used to treat muscle weakness in myasthenia gravis. Anticholinergic drugs (C) can worsen symptoms by blocking acetylcholine receptors, making them an inappropriate choice for this condition.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: A

Rationale: Rationale: - The correct answer is A, "Have you been exposed recently to anyone with an infection?" because it helps assess potential sources of infection causing the low-grade fever and other symptoms. - Choice B is irrelevant as the client's current sore throat is not the main concern. - Choice C and D do not address the potential infectious etiology of the symptoms. - Overall, assessing recent exposure to infections is crucial in identifying possible sources of the client's symptoms.

Correct Answer: A

Rationale: The correct answer is A: Pregnancy. During pregnancy, the need for iron increases significantly to support the growth of the fetus and to prevent maternal anemia. Iron is essential for the production of hemoglobin and for oxygen transport in the blood. In contrast, infants require iron for rapid growth and development, making choice B partially correct. Choice C (Old age) and choice D (Male reproductive years) are incorrect as the need for iron typically decreases in old age and remains relatively stable during male reproductive years.

Correct Answer: B

Rationale: The correct answer is B: Probenecid (Benemid). Probenecid can increase methotrexate levels, leading to potential toxicity. Methotrexate is primarily eliminated by the kidneys, and Probenecid inhibits renal tubular secretion, causing methotrexate levels to rise. Digoxin (A), theophylline (C), and famotidine (D) do not have significant interactions with methotrexate. In summary, Probenecid is the correct answer as it can increase methotrexate levels through renal tubular secretion inhibition, while the other choices do not have a significant interaction with methotrexate.

Correct Answer: D

Rationale: The correct answer is D - Patency of airway and adequacy of respiration. This is the most important assessment during the acute stage of an unconscious patient like Mr. Franco because maintaining a clear airway and ensuring proper breathing are crucial for sustaining life. Without a patent airway and adequate respiration, the patient's oxygen supply could be compromised, leading to serious complications such as hypoxia or respiratory failure. Monitoring the airway and respiratory status takes precedence over other assessments in this scenario. A: Level of awareness and response to pain - While important, assessing level of awareness and response to pain is secondary to ensuring a patent airway and adequate respiration in an unconscious patient. B: Papillary reflexes and response to sensory stimuli - While these assessments provide valuable information about neurological function, they are not as critical as maintaining a clear airway and proper breathing in an unconscious patient. C: Coherence and sense of hearing - Coherence and sense of hearing are not as vital as

Correct Answer: A

Rationale: The correct answer is A: potassium chloride. In Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone. Potassium levels are typically elevated in Addisonian crisis due to decreased aldosterone. Administering potassium chloride can further increase potassium levels, leading to life-threatening cardiac arrhythmias. Hydrocortisone (B) is essential to replace cortisol, normal saline solution (C) helps with volume resuscitation, and fludrocortisone (D) replaces aldosterone. Administering potassium chloride would exacerbate the hyperkalemia in Addisonian crisis.