Which of the following nursing interventions is correctly categorized as collaborative?

Correct Answer: D

Rationale: The correct answer is D because monitoring a client's response to an intervention initiated by another healthcare professional is a collaborative nursing intervention. This involves working together with other healthcare team members to assess the client's progress and adjust care as needed. It promotes continuity of care and ensures that the client's needs are met effectively. A: Administering medications is typically an independent nursing intervention. B: Ordering a low-sodium diet is within the scope of a nurse's independent practice. C: Providing health education is often considered an independent nursing intervention unless it involves collaboration with other team members. In summary, choice D is the correct answer as it exemplifies collaborative care within a healthcare team.

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise this part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. Collaborative problems are issues that require both medical and nursing interventions, whereas nursing diagnoses are within the scope of nursing practice. The etiology identifies the cause of the problem (tibial fracture), the nursing diagnosis states the problem (impaired physical mobility), and the defining characteristic is the evidence that supports the diagnosis (inability to ambulate). Therefore, the nurse should revise the part stating collaborative problem as it does not align with the nature of the issue presented in the scenario.

Correct Answer: B

Rationale: The correct answer is B (4 hours) because parenteral ampicillin should be administered within 1 hour of mixing. This is crucial to ensure efficacy and prevent bacterial growth in the solution. Choice A (1 hour) is incorrect because it does not allow enough time for administration after mixing. Choice C (2 hours) is also incorrect as it exceeds the recommended time limit. Choice D (8 hours) is incorrect as it exceeds the safe window for administration post-mixing, increasing the risk of bacterial contamination and reduced effectiveness. Thus, the optimal timeframe for administering parenteral ampicillin after mixing is within 4 hours to maintain its therapeutic benefits.

Correct Answer: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. This is the correct answer because the patient's fear of going home and being alone indicates apprehension about discharge, which is a common feeling among patients transitioning from the hospital to home care. This subjective data suggests that the patient may need additional support and education prior to discharge to address their fears and concerns. A: The patient can now perform the dressing changes without help - This is incorrect because the patient's fear of going home and being alone does not necessarily indicate their ability to perform dressing changes independently. B: The patient can begin retaking all of the previous medications - This is incorrect as the fear expressed by the patient is related to being alone at home, not to medication management. D: The patient’s surgery was not successful - This is incorrect as there is no indication in the subjective data provided that the surgery was not successful.

Correct Answer: C

Rationale: Rationale: C: 0.25 mg is the correct daily dosage of Digoxin for adults with heart failure. This dosage is within the usual range of 0.125-0.25 mg. It helps improve heart function and manage heart failure symptoms. A: 0.005 mg is too low and ineffective. B: 0.025 mg is also too low for therapeutic effect. D: 2.5 mg is too high and may lead to toxicity in most adult patients.

Correct Answer: C

Rationale: The correct answer is C: Cheese. Cheese is high in sodium and should be avoided on a low-sodium diet. Sodium can contribute to high blood pressure and other health issues. Apples, chicken, and broccoli are all low in sodium and can be included in a low-sodium diet. Cheese is the only option that is high in sodium, making it the correct choice to avoid.

Correct Answer: B

Rationale: Step-by-step rationale: 1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception. 2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal. 3. Hypotension (choice A) is not directly related to the Romberg test. 4. Sneezing and wheezing (choice C) are unrelated to the test. 5. Excessive cerumen in the outer ear (choice D) does not affect proprioception. Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.

Correct Answer: D

Rationale: The correct answer is D because testing the 4th (trochlear) and 6th (abducens) cranial nerves involves assessing eye movements. The trochlear nerve controls downward and inward eye movement, while the abducens nerve controls lateral eye movement. Asking the patient to follow the finger with their eyes tests the function of both nerves simultaneously. Choices A, B, and C do not specifically target the 4th and 6th cranial nerves, making them incorrect options.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.