When planning care, what factors should the nurse consider when utilizing evidence-based practice (EBP)? (Select ONE that does not apply)

Correct Answer: A

Rationale: The correct answer is A: Cost-saving measures. When utilizing evidence-based practice, the nurse should prioritize providing care based on research findings, considering client preferences, and leveraging their expertise. Cost-saving measures should not be the primary factor influencing care decisions as the focus should be on delivering the most effective and appropriate care based on evidence. Ignoring research findings, client preferences, or the nurse's expertise could compromise the quality of care provided. Thus, cost-saving measures are not a factor to consider when planning care with evidence-based practice.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Potassium. Prominent U waves on an ECG are often associated with hypokalemia (low potassium levels). Checking the potassium level immediately is crucial because hypokalemia can lead to serious cardiac complications such as arrhythmias and cardiac arrest. Option A) Sodium is less likely to cause U waves on an ECG. Sodium abnormalities typically manifest differently, such as in altered mental status or with fluid volume imbalances. Option C) Magnesium can also affect cardiac conduction, but in the context of U waves, potassium is the more immediate concern. Magnesium deficiency can lead to Torsades de Pointes and other arrhythmias. Option D) Calcium abnormalities usually present with different ECG changes and symptoms, such as QT prolongation or muscle cramps, rather than prominent U waves. Educationally, understanding the relationship between electrolyte imbalances and ECG changes is crucial for nurses and healthcare providers. Timely recognition and management of electrolyte disturbances can prevent serious cardiac consequences and improve patient outcomes. This knowledge is essential for providing safe and effective patient care in various clinical settings.

Correct Answer: C

Rationale: The correct answer is C) “The client's skeletal muscles are weak because of the low phosphorus.” This response is the best choice because phosphorus plays a crucial role in muscle function and energy metabolism. A chronically low phosphorus level can lead to muscle weakness and fatigue, making it difficult for the client to perform activities of daily living without assistance. Option A is incorrect because while malnutrition could contribute to low phosphorus levels, it does not directly explain the need for assistance with activities of daily living in this scenario. Option B is incorrect as fatigue from lack of rest is not the primary reason for the client's muscle weakness. Option D is incorrect because normalizing phosphorus levels may improve muscle function, but it does not address the current need for assistance due to low phosphorus levels. In an educational context, it is important for nursing assistants to understand the physiological impact of electrolyte imbalances on various body systems, including muscle function. This knowledge helps them provide appropriate care and support to clients with specific health needs.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Respiratory rate of 8 to 10 per minute. This finding should be reported immediately because oxycodone is an opioid medication that can cause respiratory depression as a side effect. A respiratory rate of 8 to 10 per minute indicates significant respiratory compromise and could potentially lead to respiratory arrest if not addressed promptly. Option B) Pain level decreased from 6/10 to 2/10 is not the most critical finding to report immediately. While it indicates that the pain management strategy is effective, it does not pose an immediate threat to the client's well-being. Option C) Client requests room door be closed is not a concerning finding that requires immediate reporting. It is a common patient preference that does not indicate a medical emergency. Option D) Heart rate 90-100 per minute, although slightly elevated, is not as urgent as a dangerously low respiratory rate. While tachycardia can be a sign of distress or pain, it is not as critical as respiratory depression in a patient receiving opioids. Educationally, this question highlights the importance of monitoring for and recognizing signs of opioid-related respiratory depression, a potentially life-threatening complication. It reinforces the need for vigilant assessment and prompt reporting of vital sign abnormalities in patients receiving opioid therapy, especially those with conditions like lung cancer that may further compromise respiratory function.

Correct Answer: A

Rationale: The correct answer is A) Ask her to describe her actual food intake and behaviors influencing eating. This is the initial step in conducting a nutritional assessment for Mrs. Collins who wants to lose weight. Understanding her current dietary habits, food preferences, portion sizes, eating patterns, and factors influencing her eating behaviors is crucial in developing a personalized and effective weight loss plan. Option B) Determine who does the cooking and shopping is incorrect because while it may provide some insight into Mrs. Collins' access to healthy foods, it does not directly address her individual dietary habits and behaviors. Option C) Determine what she knows about the basic four food groups is incorrect as it focuses on basic nutritional knowledge rather than Mrs. Collins' specific eating habits and behaviors. Option D) Determine biochemical data such as urinalysis and blood chemistries is incorrect because these tests are not typically the initial step in a nutritional assessment for weight loss. They may be useful later on to assess specific nutrient deficiencies or metabolic conditions, but they are not the first priority in this context. In an educational context, understanding the rationale behind each option helps nurses develop critical thinking skills to prioritize and implement appropriate interventions based on individual patient needs. By focusing on Mrs. Collins' actual food intake and eating behaviors, the nurse can gather valuable information to support her weight loss goals effectively.