The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

Correct Answer: C

Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement. Summary of Incorrect Choices: A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach. B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage. D: Measuring from the tip of the nose to the earlobe to

Correct Answer: C

Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.

Correct Answer: D

Rationale: The correct answer is D: MRI. MRI is the most appropriate test for diagnosing spinal cord compression from a tumor as it provides detailed images of soft tissues, including the spinal cord and surrounding structures. It can accurately identify the location, size, and extent of the tumor. Anterior-posterior x-ray (A) is not as detailed and may not clearly show soft tissue abnormalities. Ultrasound (B) is not typically used for imaging the spinal cord and may not provide sufficient information. Lumbar puncture (C) is used to collect cerebrospinal fluid and is not helpful for diagnosing spinal cord compression from a tumor.

Correct Answer: A

Rationale: The correct answer is A because it addresses the key issue of perception of risk among older adults. Many older adults may not perceive themselves as being at risk for HIV infection due to misconceptions or lack of awareness. This principle guides the nurse to tailor educational interventions to address this specific barrier. Choices B, C, and D are incorrect as they do not directly address the perception of risk among older adults. Older adults' awareness of HIV/AIDS, number of sex partners, or incidence of intravenous drug use are not the primary factors influencing their perception of HIV risk.

Correct Answer: D

Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function. A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange. B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise. C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.

Correct Answer: A

Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.

Correct Answer: D

Rationale: The correct answer is D because charting on the computer immediately after care is provided reduces the chances of forgetting important details and ensures accuracy. It also allows for real-time documentation, improving patient care. Choice A is incorrect as using the same password all the time poses a security risk. Choice B is incorrect as sharing passwords compromises confidentiality. Choice C is incorrect as printing out and reviewing notes at home does not address data entry errors on the computer system.

Correct Answer: A

Rationale: The correct answer is A: Hypoglycemia. Infants of diabetic mothers are at risk for hypoglycemia due to excessive insulin production in response to high glucose levels in utero. Monitoring blood glucose levels is crucial to prevent hypoglycemia-related complications. B: Hypercalcemia is not a major neonatal complication seen in infants of diabetic mothers. C: Hypoinsulinemia refers to low levels of insulin, which is not typically a concern in infants of diabetic mothers. D: Hypobilirubinemia is not a common complication in infants of diabetic mothers. In summary, monitoring for hypoglycemia is essential in infants of diabetic mothers to prevent potential complications.

Correct Answer: B

Rationale: The correct answer is B: Reinvesting in new relationships at the appropriate time. This process of mourning involves the woman gradually shifting her focus from the past relationship with her husband to forming new relationships or reinvesting in existing ones. This is crucial for her to adapt to life without her husband and move forward in a healthy manner. A: Reiterating her anger at her husband's care team is not a healthy process as it can lead to prolonged resentment and hinder the mourning process. C: Reminiscing about the relationship she had with her husband is a natural part of mourning but solely focusing on reminiscing may not allow her to fully adapt to life without her husband. D: Relinquishing old attachments to her husband at the appropriate time is important, but it is only one aspect of the mourning process. It is not the sole process necessary for healthy mourning. E: Renewing her lifelong commitment to her husband is not a healthy process as it prevents her from accepting the loss and