When following evidence-based practice, a nurse's actions are based on which sources of information?

Correct Answer: A

Rationale: Evidence-based practice (EBP) in nursing relies on robust, verifiable sources to guide actions, ensuring care is effective and safe. Published research, like peer-reviewed studies, provides the scientific backbone, offering tested interventions and outcomes. National standards, such as those from QSEN or ANA, synthesize this research into practice guidelines, ensuring consistency and quality. Targeted literature, like systematic reviews, refines focus on specific issues, enhancing relevance. Traditional knowledge, passed generationally, lacks empirical rigor and may perpetuate unproven methods, making it unreliable for EBP. Nurses using EBP prioritize these evidence-driven sources, integrating them with clinical judgment and patient needs. This approach moves care beyond habit or hearsay, grounding it in data like studies on wound care or pain relief improving outcomes and aligning with modern healthcare's demand for accountability and precision.

Correct Answer: A

Rationale: For a heart failure client doubting diet's role, the nurse promotes health by explaining its benefits watching food intake, like limiting sodium, reduces fluid buildup, easing heart strain and cutting hospital trips. This tertiary prevention approach manages the condition, improving quality of life despite damage, aligning with nursing's focus on empowerment through education. Agreeing diet doesn't matter dismisses evidence low-sodium diets improve outcomes. Suggesting food freedom with meds ignores synergy between diet and drugs. Blaming past diet shames without motivating. The positive response ties behavior to tangible gains less dyspnea, more energy encouraging adherence. Studies show dietary control slashes readmissions, making this nursing reply a practical, hopeful nudge toward self-care, vital for chronic illness management.

Correct Answer: D

Rationale: Standard precautions apply to all patients, but additional precautions (e.g., contact, droplet) depend on infection risk. Among the findings pain 9/10, watery diarrhea, jaundice, and WBC 1,000 μL (immunosuppression) WBC count of 1,000 μL (D) requires only standard precautions unless an active infection is confirmed. Pain (A) and jaundice (C) are symptoms, not contagious risks. Diarrhea (B) suggests possible infection (e.g., C. difficile), warranting contact precautions. The client's HIV status heightens infection susceptibility, but low WBC alone doesn't dictate beyond standard precautions. D is correct. Rationale: Standard precautions (hand hygiene, gloves) suffice for immunosuppression without transmissible disease; diarrhea triggers extra measures due to potential pathogen spread, per CDC guidelines, making D the least likely to escalate precautions in isolation.

Correct Answer: B

Rationale: A low-pressure alarm suggests a leak or disconnection; manual ventilation with a resuscitation bag (B) ensures immediate oxygenation while troubleshooting continues. Calling teams (A, C, D) delays airway support. B is correct. Rationale: Manual bagging maintains ventilation, a life-saving priority per ACLS and ventilator protocols, addressing potential hypoxia swiftly.

Correct Answer: A

Rationale: For a possible skull fracture, monitoring for brain injury signs (A) is the priority, detecting neurological deterioration like altered consciousness or pupil changes. Checking hemorrhage (B) is secondary. Elevating the foot (C) risks increasing ICP. Observing decreased ICP (D) is incorrect; increased ICP is the concern. A is correct. Rationale: Brain injury monitoring identifies life-threatening complications like hematoma, guiding timely intervention, per trauma care protocols, over less immediate or contraindicated actions.