What is the primary function of a written nursing care plan?

Correct Answer: D

Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.

Correct Answer: B

Rationale: In preparing a patient for a cleansing enema, the nurse typically positions the patient in the left lateral position. This position allows for the best flow of the solution due to the anatomical configuration of the colon. The right lateral position, right Sim's position, and left Sim's position are not typically used for this procedure. The rationale provided initially is incorrect as it pertains to lung expansion and postural drainage, which are not relevant to a cleansing enema procedure.

Correct Answer: D

Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.

Correct Answer: A

Rationale: The correct answer is 'Autonomy'. Autonomy refers to the patient's right to make their own decisions, which is being honored when a nurse signs a consent form. While beneficence (Choice D) is an important ethical principle that involves acting in the patient's best interest, it is not what is being primarily observed in this instance. Justice (Choice B) refers to fairness and equal treatment and is not specifically relevant to this scenario. Accountability (Choice C) pertains to being answerable for one's actions and decisions, but again, it is not the principle directly observed in this situation. Therefore, when a nurse signs a consent form, it is the principle of autonomy that is being observed.

Correct Answer: A

Rationale: In psychological terms, a 'Crisis' refers to a state of disequilibrium wherein a person cannot readily solve a problem or situation even by using his usual coping mechanisms. This is different from 'Mental Illness' (Choice C) which is a more general term for a wide range of mental health conditions that affect mood, thinking and behavior. 'Mental Health' (Choice B) is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Finally, 'Stress' (Choice D) is a state of mental or emotional strain or tension resulting from adverse or demanding circumstances, but it does not necessarily disrupt equilibrium to the extent that usual coping mechanisms are ineffective, unlike 'Crisis'.

Correct Answer: B

Rationale: Decreasing the intake of refined carbohydrates is the most effective dietary modification for a client with type 2 diabetes who aims to improve their glycemic control. Refined carbohydrates can cause sudden spikes in blood sugar levels, making diabetes management more difficult. Increasing the intake of saturated fats (Choice A) is not advisable as it can negatively impact heart health. Completely avoiding all fruits (Choice C) is unnecessary because most fruits have a low glycemic index and provide essential nutrients. Increasing the intake of sugary snacks (Choice D) will deteriorate glycemic control due to their high sugar content.

Correct Answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

Correct Answer: B

Rationale: Hypokalemia, a condition characterized by low levels of potassium in the blood, is reflected in an ECG by a widening QRS Complex and a U wave. This is because potassium plays a key role in the electrical activity of the heart, and its deficiency can lead to abnormalities in the heart's rhythm as represented by these specific changes on the ECG. Choice A is incorrect as tall T waves and pathologic Q waves are more commonly associated with hyperkalemia or myocardial infarction, respectively, rather than hypokalemia. Choices C and D are also incorrect as they do not accurately reflect the ECG changes caused by hypokalemia.

Correct Answer: D

Rationale: The correct answer is 'Develop methods for data collection' (Choice D). In the nursing research process, after the research problem has been identified, the next step would typically be to develop methods for how data will be collected. This is essential to effectively address the research problem. 'Review related literature' (Choice A), while an important step, usually occurs after the research problem has been identified and before methods for data collection are developed. 'Seek permission from the hospital administrator' (Choice B) might be necessary at some point in certain situations, but it is not the immediate next step in the research process. 'Identify the research problem' (Choice C) would typically come before developing methods for data collection. Therefore, according to the typical sequence of steps in the nursing research process, Choice D is correct.