What is the main purpose of the working phase of the nurse-patient relationship?

Correct Answer: B

Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Ecchymotic areas. The coagulation time of 20 minutes indicates a prolonged clotting time, which can lead to difficulty forming stable blood clots. Ecchymotic areas are indicative of subcutaneous bleeding under the skin, which can occur due to impaired coagulation. Observing for ecchymotic areas is crucial as it can signify potential bleeding issues in the client. Option A) Blood clots is incorrect because a prolonged coagulation time suggests difficulty in forming clots, not an excess of clot formation. Option C) Jaundice is incorrect as it is related to liver dysfunction and increased bilirubin levels, not coagulation times. Option D) Infection is also incorrect as it is not directly related to coagulation times but rather to the body's immune response. In an educational context, understanding coagulation times is essential for nurses as it helps in assessing a client's ability to form blood clots. Recognizing the implications of prolonged coagulation times, such as the risk of bleeding and ecchymosis, is crucial for providing safe and effective care to patients. Nurses must be able to interpret lab values and connect them to potential clinical manifestations to intervene promptly and appropriately.

Correct Answer: B

Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections.

Correct Answer: B

Rationale: The correct technique for using a metered-dose inhaler involves compressing the inhaler while slowly breathing in through the mouth. This method helps ensure that the medication reaches deep into the lungs, allowing for optimal bronchodilation effect. Inhaling quickly through the nose or filling the lungs with air before compressing the inhaler are not recommended techniques for using a metered-dose inhaler effectively.

Correct Answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. This step is essential for appropriate decision-making and planning further care.