You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day?

Correct Answer: B

Rationale: The correct answer is B) A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent. This client is the most appropriate to assign to the step-down unit nurse because they have stable ABGs despite being ventilator-dependent, indicating better overall respiratory function compared to the other options. Option A is incorrect because a client on a ventilator with acute respiratory failure and respiratory acidosis requires intensive care and close monitoring of their respiratory status, making them unsuitable for the step-down unit. Option C is incorrect because a new admission client with diabetic ketoacidosis on an insulin drip needs specialized care to manage their metabolic condition, which is beyond the scope of a step-down unit nurse. Option D is incorrect because a client on a ventilator with narcotic overdose and respiratory alkalosis may still require close monitoring and intervention for their overdose, making them more appropriate for the intensive care unit. In an educational context, understanding the rationale behind assigning patients based on their condition and level of care needed is crucial for nurses to prioritize patient safety and optimize outcomes. This scenario highlights the importance of matching patient acuity with nursing expertise and resources available in different units to provide appropriate care.

Correct Answer: B

Rationale: In this scenario, the most appropriate nursing measure for Jane, an obese hypertensive homemaker complaining of continual hunger and lack of energy, would be option B) Discussing the importance of eating breakfast. This choice is correct because starting the day with a balanced breakfast can help regulate blood sugar levels, boost metabolism, and provide sustained energy throughout the day. By emphasizing the importance of eating breakfast, the nurse can address Jane's hunger and lack of energy in a practical and effective manner. Option A) Giving her a list of low-calorie foods may not directly address Jane's specific concerns of hunger and lack of energy. While consuming low-calorie foods can be beneficial for weight management, it may not necessarily address the root cause of her symptoms. Option C) Recommending a strict vegetarian diet is too drastic of a dietary change to implement without further assessment of Jane's current eating habits, preferences, and nutritional needs. It may not be the most suitable recommendation for her individual situation. Option D) Suggesting vitamin supplements may not be the most appropriate initial intervention for Jane. While supplements can be beneficial in certain cases, addressing her dietary habits and meal timing should be the priority before considering additional supplementation. In an educational context, it is crucial for nurses to understand the impact of diet on health outcomes, especially in patients with comorbid conditions like obesity and hypertension. By providing tailored nutritional advice and discussing the importance of specific meal practices like eating breakfast, nurses can support patients like Jane in making sustainable lifestyle changes to improve their health and well-being.

Correct Answer: D

Rationale: In the rehabilitation of a patient with limited mobility, preventing decubitus ulcers is crucial. The correct answer is D) Keeping the skin clean, dry, and well lubricated. This is because maintaining skin integrity is essential in preventing pressure ulcers. Clean and dry skin reduces the risk of friction and irritation, while proper lubrication helps reduce shear forces on the skin. Turning the patient every 4 hours (option A) is a good practice to prevent pressure ulcers, but it is not the most effective method. Frequent repositioning is necessary, especially for patients at high risk. Using a heat lamp on reddened areas (option B) can actually worsen skin damage by increasing the risk of burns. Applying vitamin C to bony prominences (option C) may have some benefits in wound healing, but it is not the primary method for preventing decubitus ulcers. Educationally, understanding the importance of skin care and pressure ulcer prevention is critical for healthcare professionals, especially those working with immobile patients. Proper education on skin assessment, repositioning techniques, moisture control, and the use of support surfaces can significantly reduce the incidence of pressure ulcers and improve patient outcomes.

Correct Answer: D

Rationale: In pharmacology education, it is crucial for nurses to recognize that the patient must accept responsibility for compliance with their therapeutic regimen. This is the correct answer because patient adherence to medication schedules and treatment plans significantly impacts the success of the pharmacological interventions. By taking responsibility, the patient is more likely to follow through with the prescribed regimen, leading to better health outcomes. Option A is incorrect because while frustration can sometimes motivate individuals, it is not a reliable or sustainable method for enhancing a patient's desire to learn about their medications. Option B is incorrect as informal teaching plans can also be effective, and it is not limited to formal structures. Option C is incorrect because a patient's previous educational experiences greatly influence their current learning abilities and preferences. Recognizing this can help tailor teaching plans to meet the patient's needs effectively. In an educational context, understanding the importance of patient responsibility in medication compliance is fundamental for nurses. By empowering patients to take an active role in their treatment, nurses can improve medication adherence, enhance patient outcomes, and promote patient-centered care. Encouraging patients to accept responsibility for their therapeutic regimen fosters a sense of ownership and empowerment in managing their health.

Correct Answer: B

Rationale: The correct answer to the question is option B: “You feel that your life is ending, Mrs. West? Can you tell me more about your feelings?” This response demonstrates therapeutic communication by actively listening to Mrs. West, showing empathy, and encouraging her to express her emotions. It opens the door for further discussion and allows the nurse to assess Mrs. West's mental and emotional well-being. Option A is incorrect because it dismisses Mrs. West's feelings and offers false reassurance without addressing her emotional needs. Option C is incorrect as it focuses on the healthcare providers' skills rather than addressing Mrs. West's concerns. Option D is incorrect because it jumps to conclusions about the outcome of the surgery without addressing Mrs. West's emotional state or concerns. In an educational context, it is crucial for nurses to develop strong communication skills to provide holistic care to patients. Understanding the importance of therapeutic communication in addressing patients' emotional and psychological needs is essential in building trust and promoting positive patient outcomes. By actively listening, showing empathy, and encouraging open dialogue, nurses can support patients like Mrs. West through challenging situations.