A nursing instructor is reviewing steps of the nursing proce...

A nursing instructor is reviewing steps of the nursing process with students. Which of the following data are objective?

A. Respiratory rate 22/min
B. I can only walk 3 blocks before pain starts
C. Pain level 3/10
D. Skin pink warm
E. Urine output 300mL/8hr
F. Dressing clean dry intact

Correct Answer: A,D,E,F

Rationale: The correct answers are A, D, E, and F. Objective data are measurable and observable.
A: Respiratory rate 22/min is measurable.
D: Skin pink warm is observable.
E: Urine output 300mL/8hr is measurable.
F: Dressing clean dry intact is observable.
Choices B and C are subjective as they are based on the patient's perception and cannot be measured or observed directly. Choice G is incomplete.

Nurse caring for 19-year-old client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?

A. Measure the vital signs
B. Encourage HIV screening
C. Determine client's risk factors
D. Instruct client to use condoms

Correct Answer: C

Rationale: The correct answer is C: Determine client's risk factors. This is the most appropriate intervention to assess the client's health promotion and disease prevention needs. By identifying the client's risk factors such as sexual behaviors, substance use, family history, and lifestyle choices, the nurse can tailor health education and intervention strategies to promote overall well-being.

A: Measure the vital signs - While important, vital signs do not directly assess health promotion and disease prevention needs in a sexually active young adult.
B: Encourage HIV screening - Important for sexual health but does not address a comprehensive assessment of health promotion and disease prevention.
D: Instruct client to use condoms - Important recommendation for safe sex practices but does not address the broader health promotion and disease prevention needs of the client.

Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.)

A. Do you eat alone or with someone?
B. Do you watch TV while eating your meals?
C. Have you started any new meds in past 6 months?
D. What foods have you eaten in past 24 hours?
E. Are you on a fixed income?

Correct Answer: A,C,D,E

Rationale: The correct answers are A, C, D, and E.

A: Asking if the person eats alone or with someone helps to assess social factors influencing eating habits, such as loneliness or lack of social interaction affecting appetite.

C: Inquiring about new medications can reveal potential side effects like appetite changes, nausea, or malabsorption leading to weight loss.

D: Knowing the foods consumed in the past 24 hours helps identify dietary patterns that may contribute to weight loss, such as poor nutrition or reduced intake.

E: Asking about a fixed income can uncover financial constraints affecting food choices and access to nutritious meals, potentially leading to weight loss.

Summary:
B: Watching TV while eating is not directly related to weight loss causes.
F and G: Not provided in the question, so no basis to consider them as relevant questions for investigating weight loss.

By the 2nd post-op day

A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
B. Reassess client to determine reasons for pain
C. See whether pain lessens during next 24h
D. Change plan to ensure adequate pain relief
E. Teach client about pain management plan

Correct Answer: A

Rationale: Correct Answer: A

Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.

Nurse is caring for client sitting in chair & asks to return to bed. What is the priority action for the nurse?

A. Obtain walker for client to use to transfer back to bed
B. Call for additional personnel to assist with transfer
C. Use transfer belt & assist client to bed
D. Assess client's ability to help with transfer

Correct Answer: D

Rationale: The correct answer is D: Assess client's ability to help with transfer. This is the priority action because it ensures the safety of the client by determining if they are able to assist in transferring themselves back to bed. By assessing the client's ability, the nurse can prevent injury and provide appropriate assistance.

Choice A: Obtaining a walker may be helpful, but assessing the client's ability should come first to determine if it is needed.
Choice B: Calling for additional personnel is not necessary if the client can transfer independently or with minimal assistance.
Choice C: Using a transfer belt is important for safety, but assessing the client's ability should be done before assisting them.
In summary, assessing the client's ability to help with transfer is the priority to ensure safe and appropriate care.

Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field?

A. Provider drops sterile instrument onto near side of sterile field
B. Nurse moistens cotton ball with sterile NS & places it on sterile field
C. Procedure is delayed 1h because provider receives emergency call
D. Nurse turns to speak to someone who enters through door behind nurse
E. Client's hand brushes against outer edge of sterile field

Correct Answer: B,C,D

Rationale: The correct answers are B, C, and D.

B: Moistening a cotton ball with sterile NS and placing it on the sterile field introduces moisture and potentially non-sterile material, contaminating the field.
C: Delaying the procedure for an hour increases the risk of airborne contaminants settling on the sterile field.
D: Turning to speak to someone who enters behind the nurse can lead to inadvertent contact with non-sterile areas, contaminating the field.

Incorrect choices:
A: While dropping a sterile instrument close to the field is not ideal, it may not necessarily contaminate the field unless it actually touches it.
E: Client's hand brushing against the outer edge of the field is a potential contamination point, but it does not directly contaminate the sterile field.