Which of the ff nursing interventions would a nurse perform to avoid maceration from irritating drainage or the wound compresses in a client with breast abscess?

Correct Answer: A

Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration. Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe. 2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention. 3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue. 4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking. Summary: - Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking. - Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database. - Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation. - Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.

Correct Answer: C

Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient. Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider. Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order. Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse. In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.

Correct Answer: A

Rationale: Step 1: Involving the client in planning increases their understanding and ownership of the plan. Step 2: Understanding leads to better compliance with therapy recommendations. Step 3: Compliance improves outcomes and prevents complications. Step 4: Thus, choice A is correct. Choices B, C, and D lack direct links to client involvement in planning and compliance.

Correct Answer: B

Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.

Correct Answer: D

Rationale: The correct answer is D: Reassess the patient. During the initial phase of implementation, the nurse should first reassess the patient to gather current data and evaluate the effectiveness of previous interventions. This step ensures that the nurse has updated information to make informed decisions about the patient's care. A: Determining patient outcomes and goals should come after reassessment. B: Prioritizing nursing diagnoses is important but should be based on current assessment data. C: Evaluating interventions should be done after implementing them and giving them time to take effect.

Correct Answer: A

Rationale: The correct answer is A: Painless hematuria. This is an early indicator of bladder cancer because blood in the urine without pain is a common symptom in the early stages of the disease. Nocturia (B), frequent urination at night, is more commonly associated with urinary tract infections or benign prostatic hyperplasia. Occasional polyuria (C), excessive urination, can be a symptom of diabetes or kidney disease. Dysuria (D), painful urination, is more indicative of urinary tract infections or urethritis. Therefore, painless hematuria is the most specific early indicator of bladder cancer among the choices provided.

Correct Answer: C

Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.

Correct Answer: C

Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.