When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Perform the irrigation using a 20-mL syringe. This is the correct action because using a 20-mL syringe allows for precise and controlled instillation of the irrigation fluid into the catheter. Using a smaller syringe helps prevent excessive pressure within the catheter, reducing the risk of trauma or damage to the client's urinary system. A: Positioning the client in a side-lying position is not essential for open irrigation technique, as long as the client is comfortable and the procedure can be safely performed. C: Instilling 15 mL of irrigation fluid with each flush may not be appropriate as the volume needed may vary based on the client's condition. D: Although measuring and recording the amount of irrigant used is important for documentation purposes, it is not the immediate action to ensure the safe and effective irrigation of the catheter.

Correct Answer: C

Rationale: Rationale: The correct answer is C because it accurately describes the situation based on the information provided. Documenting that the client was trying to get out of bed aligns with the roommate's report of the incident. This statement is factual and relevant to the client's condition. Summary: A: Incident report completed - Not relevant to documenting the client's actions during the fall. B: Client climbed over the side rails - Assumes an action not reported by the roommate. D: Client found lying on floor - Describes the outcome, but does not explain the cause of the fall.

Correct Answer: C

Rationale: The correct answer is C because virtue ethics primarily focuses on developing moral character and virtues in individuals rather than following specific rules for behavior. This approach emphasizes the importance of cultivating virtuous traits such as honesty, courage, and kindness to guide ethical decision-making. By emphasizing moral character over rules, virtue ethics promotes the idea that individuals should strive to embody virtuous qualities to lead a good and ethical life. Choice A is incorrect because virtue ethics does not rely on rigid moral rules but rather on cultivating virtues. Choice B is incorrect because virtue ethics does not prioritize knowledge of consequences in decision-making. Choice D is incorrect because virtue ethics does not provide a formal set of rules for behavior, but rather emphasizes the development of virtuous character.

Correct Answer: D

Rationale: The correct answer is D, acuity system. This system classifies clients based on the intensity of nursing care required. It helps determine staffing needs by matching the level of care needed with appropriate staffing levels. This method ensures that the right number and type of staff are available to meet patient needs efficiently. Choice A, self-scheduling, is about allowing staff to choose their own work schedules. Choice B, supplementing staff system, refers to adding additional staff when needed, not classifying clients. Choice C, patient classification system (PCS), is a general term and does not specifically focus on nursing care intensity like the acuity system does.

Correct Answer: C

Rationale: The correct answer is C: To prevent the onset of disease. Health promotion activities aim to prevent illnesses before they occur by promoting healthy behaviors and lifestyles. This is a proactive approach that focuses on preventing diseases rather than managing or treating them after they have developed. Choice A focuses on managing existing conditions, choice B emphasizes educating patients after the fact, and choice D focuses on early detection and treatment rather than prevention. Preventing disease through health promotion is the most effective and cost-efficient approach to improving overall health outcomes.

Correct Answer: C

Rationale: The correct answer is C. This is because both options A and B are valid courses of action in this scenario. Option A suggests avoiding discussing the situation to prevent being seen as a complainer, which can be a mature approach to handle the situation diplomatically. Option B emphasizes the importance of addressing the inequity with the nurse manager to prevent increasing dissatisfaction with the job. By choosing option C, you can combine the benefits of both approaches, addressing the issue with the nurse manager while also maintaining professionalism and avoiding unnecessary conflict with colleagues.

Correct Answer: C

Rationale: The correct answer is C: Smart infusion pumps. A smart infusion pump is an example of a CDSS as it helps healthcare providers in administering medications accurately by providing alerts, dosage calculations, and other decision support tools. This system enhances patient safety and clinical outcomes. Incorrect choices: A: Electronic health record (EHR) - While EHRs store and manage patient health information, they do not provide decision support features like CDSS. B: Barcode medication administration - While barcoding helps in verifying medication administration, it is not a CDSS that provides clinical decision support. D: Automated drug dispensing system - While these systems help in dispensing medications accurately, they do not provide clinical decision support tools like smart infusion pumps do.

Correct Answer: A

Rationale: The correct answer is A: "I need to rotate injection sites among my arms, legs, and abdomen each day." This statement indicates a need for additional instruction because rotating injection sites within the same day is not recommended. Insulin injections should be given at the same general time each day but rotated within the same anatomical site to avoid inconsistent absorption rates and potential lipohypertrophy. Choices B, C, and D all demonstrate correct understanding of insulin administration techniques, including syringe selection based on markings, correct order of drawing up insulin types, and the lack of need to aspirate the plunger to check for blood before injecting.

Correct Answer: B

Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for skin health and wound healing. Carbohydrates provide energy for the body's healing processes. Skin breakdown can be prevented by ensuring the client has a well-balanced diet. A: Placing the client in high-Fowler's position is not directly related to preventing skin breakdown in this scenario. C: Massaging areas of skin that are darker than the surrounding skin tissue with lotion may cause more harm than good, as it can increase the risk of skin breakdown. D: Having the client use a trapeze bar when changing position is important for mobility but does not directly address the prevention of skin breakdown.