To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;

Correct Answer: A

Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is crucial for preventing infection when accessing or caring for an invasive monitoring system like a subdural intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field, washing hands, using sterile gloves, and using sterile supplies to minimize the risk of contamination. This is essential to prevent introducing harmful microorganisms into the patient's system. Using clean technique (B) or sterile technique only when cleansing the insertion site (C) may not provide adequate protection against infection. Closing leaks in the tubing with tape (D) is not an appropriate method for preventing infection and can lead to complications.

Correct Answer: A

Rationale: The correct answer is A: Liver. The liver is a common site for metastasis because it receives blood from various organs, making it a prime location for cancer cells to travel and establish secondary tumors. Additionally, the liver has a rich blood supply and provides a favorable environment for cancer cells to thrive. In contrast, B (Reproductive tract) and C (Colon) are not as common sites for metastasis compared to the liver. Choice D (White blood cells) is incorrect as metastasis involves the spread of cancer cells to distant organs, not within the blood cells themselves.

Correct Answer: A

Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is crucial for preventing infection when accessing or caring for an invasive monitoring system like a subdural intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field, washing hands, using sterile gloves, and using sterile supplies to minimize the risk of contamination. This is essential to prevent introducing harmful microorganisms into the patient's system. Using clean technique (B) or sterile technique only when cleansing the insertion site (C) may not provide adequate protection against infection. Closing leaks in the tubing with tape (D) is not an appropriate method for preventing infection and can lead to complications.

Correct Answer: B

Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan. A: Documenting interventions is important but not the primary focus during the evaluation phase. C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan. D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.

Correct Answer: A

Rationale: The correct answer is A: Increased ICP. Decreasing level of consciousness is a classic sign of increased intracranial pressure (ICP) due to the compression of the brain. As ICP rises, it impairs cerebral perfusion leading to altered mental status. Parasympathetic response (B) and sympathetic response (C) are related to autonomic nervous system functions, not consciousness. Increased cerebral blood flow (D) might lead to conditions like hyperemia but does not directly cause a decreased level of consciousness.

Correct Answer: C

Rationale: The correct answer is C because it helps the patient explore her support system. By asking who she usually goes to when facing problems, the nurse encourages the patient to identify her sources of emotional support, which can help her cope with the new diagnosis. This response acknowledges the patient's need for support and fosters a therapeutic relationship. Explanation for incorrect choices: A: "Don't worry. You'll be okay." - This response dismisses the patient's feelings and offers false reassurance, which may not address her emotional needs. B: "The treatments you are receiving will make you feel better very soon." - While this statement provides information about treatment, it does not directly address the patient's difficulty in coping with the diagnosis. D: "Have you made end-of-life decisions?" - This response may be premature and could unnecessarily increase the patient's anxiety about her prognosis.

Correct Answer: B

Rationale: The correct answer is B: maintain blood pressure control. After PTCA, the priority goal is to ensure stable hemodynamics. Maintaining blood pressure control is crucial to prevent complications such as bleeding or thrombosis. Choices A, C, and D are incorrect because preventing fluid volume deficit, decreasing myocardial contractility, and minimizing dyspnea are not immediate priorities post-PTCA. Oxygenation and hemodynamic stability take precedence over these concerns.

Correct Answer: A

Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances. Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.

Correct Answer: C

Rationale: The correct answer is C: Non-mobile mass with irregular edges. A non-mobile mass with irregular edges is more likely to be cancerous as it indicates potential infiltration into surrounding tissues. This finding raises suspicion for malignancy as cancerous lumps tend to have irregular shapes due to their invasive nature. In contrast, options A and B describe characteristics of benign masses, such as mobile, soft, and easily delineated. Option D indicates no palpable lymph nodes, which does not directly correlate with the characteristics of the breast lump. Therefore, option C is the most concerning and indicative of a potentially cancerous lesion based on the assessment findings provided.