Which of the following examples of client data needs to be validated?

Correct Answer: A

Rationale: The correct answer is A because validating the client's statement about not needing glasses is crucial for accurate data collection. This step ensures that the client's difficulty reading is not due to poor eyesight. - Choice B is about interpreting physical signs, not client data validation. - Choice C involves documenting objective findings, not validating client information. - Choice D pertains to a client's complaint, not necessarily requiring validation.

Correct Answer: B

Rationale: The correct answer is B: Lifetime dependency on hormone replacement. After hypophysectomy, the pituitary gland is removed, leading to a deficiency in essential hormones. Patients will need lifelong hormone replacement therapy to maintain normal body functions. This is crucial for regulating metabolism, growth, reproduction, and stress response. Choices A, C, and D are incorrect because abnormal distribution of body hair, increased fluid intake, and repeat surgical procedures are not typically associated with hypophysectomy. It is essential to focus on the long-term management of hormone replacement therapy to ensure the patient's overall health and well-being.

Correct Answer: B

Rationale: The correct answer is B, notifying the health care provider. This is the most appropriate initial intervention because chest pain can be a symptom of a serious medical condition like a heart attack. The health care provider needs to be informed immediately to assess the situation and provide appropriate treatment. Reassessing the patient (A) may delay crucial medical intervention. Administering pain medication (C) without knowing the cause of chest pain can be dangerous. Calling radiology for a chest x-ray (D) is not the initial step in managing new onset chest pain.

Correct Answer: B

Rationale: The correct answer is B because using a PICOT question involves formulating a research question to guide evidence-based practice. B indicates the nurse is implementing interventions based on scientific research, aligning with the PICOT framework (Patient, Intervention, Comparison, Outcome, Timeframe). This approach ensures that care decisions are supported by the best available evidence, leading to improved patient outcomes. Choice A is incorrect because practicing nursing based on court evidence does not align with the PICOT framework. Choice C is incorrect as using standardized care plans for all patients may not consider individual patient needs and preferences as required in a PICOT question. Choice D is incorrect as planning care based on tradition does not involve integrating current research evidence as in the PICOT approach.

Correct Answer: B

Rationale: The correct answer is B: Hemorrhage. The nurse manager would intervene because hemorrhage is a life-threatening condition requiring immediate attention. Wandering (A), urinary retention (C), and impaired swallowing (D) are important assessments but do not pose the same level of immediate risk as hemorrhage. The nurse manager would prioritize addressing the hemorrhage to ensure the patient's safety and well-being.

Correct Answer: C

Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications. - Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately. - Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status. - Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.

Correct Answer: C

Rationale: The correct answer is C because data validation involves comparing data with other sources to ensure accuracy. This process checks for errors, inconsistencies, and completeness in the data. By comparing data with other sources, nurses can verify the reliability and correctness of the information. Choice A is incorrect because data validation typically occurs after data collection and before data interpretation. Choice B is incorrect because validation is about ensuring data accuracy, not about professional standards. Choice D is incorrect because data interpretation focuses on analyzing and making sense of the data, not on professional standards or validation processes.

Correct Answer: B

Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Providing oral care does not directly address fluid balance or hydration status. 2. Oral care focuses on maintaining oral hygiene and preventing infections. 3. Choices A, B, and D all involve fluid intake to address dehydration. 4. Offering large amounts of fluid, enteral or parenteral fluids, and small volumes at frequent intervals all aim to correct the patient's condition by replenishing lost fluids. Summary: Choice C is incorrect because oral care does not directly address the patient's dehydration. Choices A, B, and D are better options as they focus on fluid replacement to correct the patient's condition.