When the nurse is administering furosemide 40 mg IV push to a client in congestive heart failure (CHF), what phase of the nursing process does this represent?

Correct Answer: C

Rationale: The correct answer is C: Implementation. This is because administering furosemide 40 mg IV push to a client in CHF is an action that falls under the Implementation phase of the nursing process, where the nurse carries out the planned interventions to help achieve the client's goals. Assessment (A) is the data collection phase, Planning (B) involves setting goals and determining interventions, and Evaluation (D) is the phase where the nurse assesses the effectiveness of the interventions. In this case, actually administering the medication is executing the planned intervention, thus categorizing it under Implementation.

Correct Answer: D

Rationale: The correct answer is D. Holding potassium chloride (KCl) and calling the healthcare provider (HCP) is crucial because administering electrolytes without proper assessment can be dangerous. If the electrolyte panel shows abnormal levels, especially for potassium, the nurse must seek guidance from the healthcare provider to prevent potential harm. Re-checking the client's basic metabolic panel (BMP) (choice A) may not provide specific information about the electrolyte imbalance. Administering calcium carbonate (choice B) may not address the specific electrolyte imbalance revealed in the panel. Administering potassium chloride (KCl) (choice C) without further assessment and guidance could worsen the imbalance.

Correct Answer: B

Rationale: The correct answer is B: 5 minutes. This is because the nurse should listen for a minimum of 5 minutes to accurately determine if bowel sounds are absent. Bowel sounds may be irregular and taking the time to listen for a longer period increases the chances of detecting any sounds. Listening for only 1 minute (choice A) may not provide a comprehensive assessment. Listening for 10 minutes (choice C) or 15 minutes (choice D) is unnecessary and may lead to unnecessary delays in patient care.

Correct Answer: C

Rationale: Step 1: Body mechanics involve using proper posture and movements to prevent injury. Step 2: By applying body mechanics, both the client and nurse can avoid strains and injuries. Step 3: The primary goal of using body mechanics is to prevent harm to both parties involved. Step 4: Choice C correctly states that body mechanics aim to prevent injury to both the client and nurse. Summary: Choice A is incorrect as it only focuses on protecting the client. Choice B is incorrect as it only focuses on protecting the nurse. Choice D is incorrect as the main goal of body mechanics is not related to legal action but rather injury prevention for both parties.

Correct Answer: D

Rationale: The correct answer is D) licensed practical nurse (LPN)/licensed vocational nurse (LVN). LPN/LVN programs are specifically designed to prepare individuals for entry-level positions in healthcare as practical/vocational nurses. Graduates from these programs must pass the NCLEX-PN exam to obtain licensure and practice as LPNs/LVNs. Option A) associate degree in nursing (ADN) and option B) bachelor of science in nursing (BSN) are nursing programs that prepare individuals to become registered nurses (RNs) rather than LPNs/LVNs. RNs have a higher level of education and scope of practice compared to LPNs/LVNs. Option C) master of science in nursing (MSN) is a graduate-level program designed for nurses who wish to advance their knowledge and skills in specialized areas of nursing practice or leadership roles. MSN-prepared nurses typically do not start at an entry-level position that requires passing the NCLEX-PN exam. Understanding the distinctions between these nursing programs is crucial for students pursuing a career in nursing to make informed decisions about their educational pathways and future career goals. The LPN/LVN program is a valuable option for individuals seeking a more direct route to entry-level nursing practice in healthcare settings.