Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?

Correct Answer: A

Rationale: The correct answer is A because a low O2 saturation level indicates poor oxygenation, which is critical in ADHF. Step 1: Check airway patency and oxygen delivery. Step 2: Administer supplemental oxygen. Step 3: Monitor for improvement in O2 saturation. Choices B, C, and D are important but not as urgent. B: Weight gain can indicate fluid retention but not an immediate threat. C: Elevated heart rate is common in ADHF but not immediately life-threatening. D: Decreased urine output may indicate renal dysfunction, but not as urgent as addressing poor oxygenation.

Correct Answer: C

Rationale: The correct answer is C: a focus on the health of the community. Community-based care emphasizes promoting health and wellness within the community, addressing the specific needs and challenges of the population. This approach involves collaboration with community members, organizations, and resources to improve overall health outcomes. This choice directly aligns with the concept of community-based care, reflecting a comprehensive and holistic approach to healthcare. Summary of other choices: A: While care may be provided within a defined area in community-based care, the focus is not solely on geography but on the community's overall health. B: Community-based care is not limited to mental health but encompasses all aspects of healthcare. D: Population-based care is a broader concept that focuses on health outcomes at the population level, whereas community-based care is more specific to the community's health needs.

Correct Answer: B

Rationale: The correct answer is B: American Nurses Association. The ANA first legitimized the nursing process in the 1973 publication "Nursing: A Social Policy Statement." This document outlined the importance of the nursing process as a systematic and scientific approach to providing patient care. The ANA's endorsement of the nursing process set the standard for nursing practice and education. A: The National League for Nursing focuses more on nursing education standards and accreditation. C: The International Council of Nursing is a global organization that promotes nursing on an international level. D: State Boards of Nursing regulate nursing practice at the state level but do not have the authority to legitimize the nursing process on a national scale.

Correct Answer: A

Rationale: Correct Answer: A Rationale: Choice A is a breach of patient confidentiality because discussing patient information in a public area like an elevator violates the patient's right to privacy. Confidential patient information should only be discussed in private, secure locations to protect the patient's confidentiality. Summary of other choices: B: Sharing a computer password with a relative of a patient is a breach of security protocols but not necessarily a breach of patient confidentiality unless the password provides access to patient information. C: Checking a patient's medical record for emergency contact information is not a breach of patient confidentiality as long as it is done for appropriate medical reasons and does not involve sharing the information with unauthorized individuals. D: Updating an employer about a patient's return to work does not violate patient confidentiality if done with the patient's consent and does not disclose sensitive medical information.

Correct Answer: A

Rationale: The primary purpose of an incident report is to identify risks. Firstly, it helps in recognizing potential hazards or gaps in safety protocols. Secondly, it aids in implementing strategies to prevent similar incidents. Lastly, it assists in improving overall safety measures and creating a safer environment. The other choices are incorrect because incident reports are not primarily used for staff evaluation, disciplinary action, or as a format for audiotaped reports. These purposes do not align with the main objective of identifying risks and improving safety protocols.