Choice A rationale:

Health education involves providing information and knowledge to clients about their health, which is essential but doesn't directly relate to the nurse's action of blood pressure screening. This choice is less appropriate in this context.

Choice B rationale:

Health promotion encompasses actions that aim to enhance an individual's well-being and prevent illness. Blood pressure screening is a preventive measure to identify individuals at risk of hypertension, making it a key component of health promotion. The nurse is contributing to the client's overall health by identifying potential hypertension issues.

Choice C rationale:

Holistic health refers to a broader approach to healthcare that considers the physical, mental, and social aspects of an individual. While it's essential, the nurse's specific action of blood pressure screening doesn't necessarily encompass all these aspects. It's more focused on identifying a specific health condition.

Choice D rationale:

Disease prevention involves activities to prevent the occurrence or progression of diseases. Blood pressure screening falls under this category as it aims to prevent complications related to hypertension, making this choice a relevant consideration. However, "Health promotion" is a more precise and comprehensive description of the nurse's role in this scenario.

Choice A rationale:

Health education involves providing information and knowledge to clients, but the nurse's action of blood pressure screening goes beyond mere education. It involves the actual screening for a specific health condition, which aligns better with health promotion.

Choice B rationale:

Health promotion encompasses actions aimed at enhancing an individual's well-being and preventing illness. Blood pressure screening is a preventive measure to identify individuals at risk of hypertension, making it a crucial component of health promotion. The nurse is contributing to the client's overall health by identifying potential hypertension issues.

Choice C rationale:

Holistic health refers to a broader approach to healthcare that considers the physical, mental, and social aspects of an individual. While it's important, the nurse's specific action of blood pressure screening doesn't necessarily encompass all these aspects. It's more focused on identifying a specific health condition.

Choice D rationale:

Disease prevention involves activities to prevent the occurrence or progression of diseases. Blood pressure screening falls under this category as it aims to prevent complications related to hypertension, making this choice a relevant consideration. However, "Health promotion" is a more precise and comprehensive description of the nurse's role in this scenario.

Choice A rationale:

Skilled nursing is the most appropriate resource to anticipate for a postoperative client who needs physical therapy 2-3 times per day for two weeks. Skilled nursing facilities provide care from licensed nurses and therapists, making them well-suited for short-term rehabilitation and therapy services. These facilities offer a higher level of medical care compared to the other options, ensuring that the client's postoperative needs are adequately met.

Choice B rationale:

Assisted living is not the most suitable option for a postoperative client who requires physical therapy multiple times a day. Assisted living facilities are generally designed for individuals who need assistance with daily activities but do not require constant medical or therapeutic interventions.

Choice C rationale:

Long-term care is not the appropriate choice for a postoperative client with a two-week prescription for physical therapy. Long-term care facilities are designed for individuals who require ongoing, extended care, often due to chronic illnesses or disabilities. The client's condition is temporary, so long-term care is not warranted.

Choice D rationale:

Palliative care is intended for clients with serious, life-limiting illnesses, focusing on pain management and improving the quality of life. It is not suitable for a postoperative client who needs physical therapy for a limited duration. The primary goal of palliative care is different from the client's needs in this scenario.

Choice A rationale:

TJC (The Joint Commission) does not provide licensure for healthcare providers. Licensing is typically issued by state regulatory bodies, and it ensures that healthcare professionals meet the minimum qualifications and standards to practice within their respective states. TJC's role is different from providing licensure.

Choice B rationale:

TJC is primarily responsible for accrediting healthcare facilities, including hospitals and clinics, to ensure that they meet specific quality and safety standards. Accreditation by TJC is a mark of quality and demonstrates that the facility complies with nationally recognized healthcare standards.

Choice C rationale:

TJC is not a for-profit organization. It is an independent, non-profit organization dedicated to improving healthcare quality and safety. It does not seek to generate profits but rather focuses on enhancing the quality of care provided to patients.

Choice D rationale:

TJC is not an organization that monitors insurance claims. Monitoring insurance claims is typically the responsibility of insurance companies and regulatory agencies. TJC's primary role is to assess and accredit healthcare facilities to promote patient safety and quality care.

Choice A rationale:

A heart rate of 56 beats per minute is within the normal range for an adult, so a high temperature of 39°C (102.2°F) is not directly related to the heart rate. While elevated body temperature can increase heart rate, the given temperature does not indicate a significant fever.

Choice B rationale:

History of cigarette smoking may be a risk factor for cardiovascular issues, but it does not directly correlate with the current heart rate of 56 beats per minute. The low heart rate is more likely related to other factors.

Choice C rationale:

A heart rate of 56 beats per minute is considered bradycardia, which can lead to dizziness, fatigue, and other symptoms. Dizziness is a common finding in individuals with a slow heart rate, and addressing this symptom is essential for patient safety.

Choice D rationale:

Hypoglycemia (low blood sugar) can cause symptoms like dizziness, but the heart rate is not typically affected directly by hypoglycemia. It is important to address both the bradycardia and the reported dizziness to determine the underlying cause and provide appropriate care.

Choice A rationale:

The statement "Identifies viruses across the world" is not an accurate description of the Healthy People 2030 framework. This framework focuses on health objectives and goals for Americans, not the identification of viruses. It is designed to improve the health and well-being of people in the United States, not to identify viruses globally.

Choice C rationale:

The statement "Utilizes health data from the past 20 years" is not a primary purpose of the Healthy People 2030 framework. While it may incorporate historical health data to inform its objectives, the framework's main goal is to set health objectives for the future, not exclusively based on past data. It aims to address current and future health needs and challenges.

Choice D rationale:

The statement "Monitors nonmodifiable risk factors" does not accurately describe the main focus of the Healthy People 2030 framework. While the framework may consider various health risk factors, it primarily concentrates on setting health objectives and goals to improve the health of Americans. The monitoring of nonmodifiable risk factors is not its central purpose.

Choice B rationale:
The statement "The ACA is primarily for individuals requiring tertiary care" is not accurate. The Affordable Care Act (ACA) is designed to improve access to healthcare for a broad range of individuals, not just those in need of tertiary care. It aims to make healthcare coverage more affordable and accessible for all, regardless of the level of care needed.
Choice C rationale:
The statement "Individuals must qualify to participate in ACA insurance coverage" is correct to some extent. Individuals must meet certain eligibility criteria to enroll in ACA insurance plans, such as being a U.S. citizen or lawfully present, but it does not capture the full scope of the ACA's purpose. The primary goal of the ACA is to expand access to healthcare and reduce disparities, not just limited to qualification requirements.
Choice D rationale:
The statement "Individuals with pre-existing conditions are not eligible for ACA coverage" is incorrect. One of the significant achievements of the ACA is that it prohibits insurance companies from denying coverage to individuals with pre-existing conditions. In fact, the ACA has provisions to protect individuals with pre-existing conditions and ensure their access to insurance coverage.

Choice A rationale:

While the principle of justice is essential in healthcare, it does not directly address the client's decision to proceed with elective surgery or not. Justice pertains more to the fair allocation of resources and the equitable treatment of individuals, which may not directly apply to the client's autonomy in this situation.

Choice B rationale:

The principle of fidelity relates to keeping promises and being faithful to commitments, but it may not be the primary ethical principle to consider in this situation. The client's decision to proceed with elective surgery is primarily a matter of personal autonomy, and the nurse should prioritize respecting the client's autonomy over fidelity.

Choice C rationale:

Veracity is the principle of truthfulness and honesty in communication, but it does not take precedence over the client's autonomy in this context. While it is important for the nurse to provide honest information, the client's autonomous decision to proceed with or decline surgery should be respected regardless of the nurse's communication of truthful information. .

Choice A rationale:

The nurse should not inform the client of the need to pre-pay for the consent of authorization. Precertification for surgery is related to obtaining approval from the client's insurance provider and not about pre-payment.

Choice B rationale:

Contacting the client's insurance carrier to obtain authorization is the correct action to take when obtaining precertification for surgery. Many insurance companies require pre-authorization for surgical procedures to ensure coverage and to confirm that the procedure is medically necessary. This step is essential to prevent financial burdens on the client and ensure they have coverage for the surgery.

Choice C rationale:

Notifying the provider to obtain approval for the surgery is not the nurse's responsibility in the context of precertification. The primary responsibility lies with obtaining approval from the client's insurance carrier.

Choice D rationale:

Witnessing the client sign the surgical consent form is an essential step in the surgical preparation process but is not the same as obtaining precertification. Precertification involves confirming insurance coverage and approval for the surgery, which is the responsibility of the insurance carrier, not the client's consent.

Choice A rationale:

Guiding the client away from background noise is a helpful suggestion for a client with hearing loss, but in the context of reviewing discharge instructions, it may not be sufficient. The primary issue is not background noise but the ability of the client to hear and understand the nurse's instructions.

Choice B rationale:

Providing a copy of the instructions printed in Braille is not appropriate for a client with hearing loss. Braille is a tactile reading and writing system for people who are blind or visually impaired. It does not address the client's hearing loss.

Choice C rationale:

Standing next to the client when speaking is the most appropriate action for a nurse when reviewing discharge instructions with a client who has hearing loss. This allows the client to see the nurse's facial expressions, lip movements, and gestures, which can aid in understanding. It also minimizes the distance between the nurse's mouth and the client's ears, making it easier for the client to hear.

Choice D rationale:

While repeating phrases that the client misunderstands is a helpful communication strategy, it should be used in conjunction with standing close to the client, not as the sole method. Standing close and speaking clearly should be the primary approach to facilitate effective communication with a client who has hearing loss.

Choice A rationale:

The National Student Nurses Association is primarily focused on students and recent graduates. While it can be an excellent organization for student nurses, it may not provide opportunities for a nurse looking to become involved in nursing on a national level beyond their student years.

Choice B rationale:

The National Academy of Medicine is an organization that focuses on health policy and research. While it is a prestigious organization, it is not specifically a nursing organization, and its focus may not align with the goals of a nurse seeking to become more involved in nursing on a national level.

Choice C rationale:

The American Nurses Association (ANA) is a national organization specifically dedicated to advancing the nursing profession. It offers various opportunities for nurses to get involved in national-level nursing advocacy, policy development, and professional growth. Joining the ANA is a suitable choice for a nurse looking to make a national impact in the field of nursing.

Choice D rationale:

The National League for Nursing (NLN) is an organization that primarily focuses on nursing education. While it plays a crucial role in the field of nursing, its focus is more on education and may not align with a nurse's goal to become involved in nursing on a national level from a broader perspective.

Choice A rationale:

Assessment Assessment is the first step of the nursing process, where the nurse collects data about the patient's condition. While this step is crucial for understanding the patient's needs, it does not involve formulating goals for a positive outcome. Therefore, it is not the correct choice in this context.

Choice B rationale:

Planning Planning is the step of the nursing process where the nurse formulates goals and develops a care plan to achieve those goals. This includes setting objectives for the patient's care and determining the best course of action. In this case, the nurse is formulating goals for a positive outcome, making choice B the correct answer.

Choice C rationale:

Evaluation Evaluation is the step where the nurse assesses the patient's response to the care provided and determines whether the goals have been met. While important, it does not involve the initial formulation of goals, so it is not the correct choice for this question.

Choice D rationale:

Implementation Implementation involves carrying out the plan of care, putting the planned interventions into action. It doesn't focus on goal formulation, so it is not the correct answer in this context.

Choice A rationale:

Tell the APs they are acting immature. Telling the APs that they are acting immature is a judgmental and unhelpful approach. It does not demonstrate conflict resolution but rather exacerbates the conflict. This choice is not appropriate for resolving the situation.

Choice B rationale:

Allow the APs to resolve their issues. While allowing individuals to resolve their issues on their own can sometimes work, it is not always the best approach, especially in a healthcare setting where teamwork and patient care are paramount. In this scenario, the nurse should play an active role in resolving the conflict, making this choice less suitable.

Choice C rationale:

Confront the APs to discuss their argument. Confronting the APs to discuss their argument is a proactive approach to conflict resolution. It allows the nurse to address the issue, mediate the disagreement, and work towards a resolution. This choice is the most appropriate and demonstrates effective conflict resolution.

Choice D rationale:

Report the APs to the charge nurse. Reporting the APs to the charge nurse should be considered when the conflict cannot be resolved at the staff level, and it threatens patient care or safety. However, it should not be the first step in resolving a conflict between two individuals. It is a more formal and escalated approach, and in this case, choice C is a more suitable initial response.

a. Using medical jargon

• Rationale: Medical jargon can be precise and efficient for communication among healthcare professionals. However, it can be confusing and intimidating for patients or non-medical staff, which is not therapeutic.

b. Active listening

• Rationale: Active listening involves fully focusing, understanding, responding and then remembering what is being said. It is a fundamental component of therapeutic communication as it shows respect and understanding for the speaker, builds trust, and helps to facilitate a deeper understanding of a patient’s perspective and needs.

c. Giving advice

• Rationale: While it might seem helpful to give advice, it can often disempower the patient or make them feel like they are not being heard. Therapeutic communication should be patient-centered and empowering.

d. Using closed-ended questions

• Rationale: Closed-ended questions can be useful for gathering specific information quickly. However, they limit the depth of response and can shut down communication, making them less therapeutic.

The correct answer isb. Active listening. This technique is a key component of therapeutic communication as it encourages a deeper understanding and is respectful and patient-centered. It helps in building a therapeutic nurse-patient relationship.

Choice A rationale:

The calculation for the required mL of lidocaine is done as follows: (Desired dose in mg) / (Concentration in mg/mL) = mL to be administered. In this case, the desired dose is 50 mg, and the concentration is 200 mg/mL. Therefore, the calculation is: (50 mg) / (200 mg/mL) = 0.25 mL. The nurse should administer 0.25 mL, not 0.3 mL as in choice A.

Choice B rationale:

As calculated above, the correct amount of lidocaine to be administered is 0.25 mL, which is rounded to 0.2 mL. This is the correct choice.

Choice C rationale:

Choice C suggests administering 0.4 mL, which is not the correct calculation. The correct answer, as calculated, is 0.2 mL.

Choice D rationale:

Choice D suggests administering 0.1 mL, which is incorrect. The correct answer, as calculated, is 0.2 mL.

Choice A rationale:

Justice is the ethical principle related to fairness and equality in healthcare. It is not applicable in this scenario as it does not address the nurse's action of returning at 1400 for wound care.

Choice B rationale:

Autonomy is the principle that respects a patient's right to make decisions about their own healthcare. While important, this is not the focus of the nurse's action in this scenario.

Choice C rationale:

Veracity refers to truthfulness and honesty in healthcare. The nurse returning at the agreed time of 1400 does not primarily relate to veracity. It is more about keeping a commitment.

Choice D rationale:

Fidelity, or faithfulness, is the ethical principle that the nurse is demonstrating in this scenario. The nurse is keeping their commitment to provide wound care at the agreed time of 1400. This aligns with the principle of fidelity.

Choice A rationale:

Standards of care for monitoring clients with a history of blood pressure elevation are important, but they are not the best resource for health promotion activities for clients with hypertension. This choice is more focused on monitoring and care standards.

Choice B rationale:

A critical pathway for clients who have had a stroke is specific to a different condition and not related to health promotion for clients with hypertension. It does not provide the information needed for the presentation.

Choice C rationale:

Acute care facility protocol for clients experiencing a hypertensive crisis is important for managing emergencies, but it is not the best resource for health promotion activities. It deals with crisis management rather than prevention.

Choice D rationale:

Clinical practice guidelines for the management of high blood pressure are the most appropriate resource for the nurse's presentation on health promotion activities for clients with hypertension. These guidelines provide evidence-based recommendations for managing and preventing high blood pressure, making them the best choice for the presentation. .

Choice A rationale:

Systematic reviews are considered Level I evidence in the hierarchy of evidence in evidence-based practice (EBP). Systematic reviews involve the rigorous and comprehensive synthesis of multiple research studies on a specific topic. This approach minimizes bias and provides the highest level of evidence for making clinical decisions. Systematic reviews typically follow a structured methodology and offer a critical analysis of the existing literature, making them a strong foundation for EBP.

Choice B rationale:

Credible websites are not considered Level I evidence. While some websites may contain reliable information, they vary in quality, and the credibility of the source must be carefully assessed. Relying solely on websites is not the most robust approach in EBP, as it lacks the rigorous systematic review and critical appraisal process of Level I evidence.

Choice C rationale:

Expert opinions are not considered Level I evidence. While expert opinions can be valuable, they are often based on individual experiences and interpretations rather than systematic research. Expert opinions are generally considered lower in the hierarchy of evidence compared to systematic reviews and other forms of research evidence.

Choice D rationale:

Qualitative studies are not considered Level I evidence. Qualitative studies provide valuable insights into the experiences, perceptions, and meanings associated with a particular phenomenon. However, they are typically ranked lower in the hierarchy of evidence compared to systematic reviews and quantitative research studies. Qualitative studies are more appropriate for addressing research questions related to subjective experiences and understanding the "why" and "how" of a phenomenon.

Choice A rationale:

Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.

Choice B rationale:

Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.

Choice C rationale:

Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.

Choice D rationale:

SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.

Choice A rationale:

"The use of social media is not included in the COE.”. This statement is not accurate. The use of social media is addressed in the Code of Ethics (COE) for nurses. The COE provides guidance on how nurses should maintain professional boundaries and ethical behavior in the digital age, which includes considerations for social media use.

Choice B rationale:

"Professional expectations are included in the COE.”. This statement is correct. The Code of Ethics (COE) for nurses outlines the professional expectations and standards that nurses are expected to adhere to. It provides guidance on ethical conduct, accountability, and the responsibilities of nurses in their practice.

Choice C rationale:

"Student nurses are not held accountable to COE.”. This statement is not accurate. Student nurses are expected to adhere to the same ethical standards outlined in the Code of Ethics (COE) as registered nurses. While there may be some variations in practice expectations based on the level of training, ethical principles apply to all nurses, including student nurses.

Choice D rationale:

"Criteria for obtaining licensure is included in the COE.”. This statement is not accurate. The Code of Ethics (COE) primarily focuses on ethical principles, professional behavior, and the responsibilities of nurses in their practice. It does not typically include criteria for obtaining licensure, as licensure requirements are determined by licensing boards and regulatory bodies.

Answer and explanation

The correct answer is choice B.

Choice A rationale:

Yoga involves gentle stretching and may not directly impact the phlebitis.

Choice B rationale:

Therapeutic massage could potentially dislodge a clot in the leg, leading to a dangerous condition called a pulmonary embolism.

Choice C rationale:

Acupressure, like yoga, involves gentle pressure and may not directly impact the phlebitis.

Choice D rationale:

Acupuncture involves the insertion of needles and could potentially cause harm, but it is less likely to dislodge a clot than massage.

Choice A rationale:
Hyperlipidemia is a condition characterized by elevated levels of lipids (cholesterol and triglycerides) in the blood. High lipid levels are associated with atherosclerosis and impaired blood flow, which can hinder wound healing. Therefore, having hyperlipidemia places the client at risk for delayed wound healing.
Choice B rationale:
Diabetes mellitus is a chronic condition that can lead to impaired wound healing. High blood sugar levels in diabetes can damage blood vessels and nerves, reducing blood flow to wounds and impairing the body's ability to fight infection. Therefore, diabetes mellitus places the client at risk for delayed wound healing.
Choice C rationale:
The medication history is a crucial factor to consider in wound healing. Prednisolone, a corticosteroid, can suppress the immune system and impair the body's ability to heal wounds. Long-term use of prednisolone, as in this case (20 mg/day for the past 2 years), increases the risk of delayed wound healing. Therefore, the medication history places the client at risk for delayed wound healing.
Choice D rationale:
The cholesterol level, in this context, is less relevant to the immediate risk of delayed wound healing. While high cholesterol levels are a risk factor for atherosclerosis and cardiovascular diseases, they do not have a direct impact on wound healing. The other choices (A, B, and C) are more directly related to delayed wound healing in the context of this surgical patient.
Choice E rationale:
Prealbumin is a protein that reflects a person's nutritional status. A low prealbumin level indicates malnutrition or inadequate protein intake, which can hinder wound healing. Therefore, a low prealbumin level places the client at risk for delayed wound healing. Now, let's move on to the last question.

Choice A rationale:

The nurse should clarify the systolic blood pressure because the documentation states "Blood pressure 102/58 mm Hg.”. Blood pressure readings are always presented as a ratio of two numbers, with the systolic pressure (the higher number) representing the pressure in the arteries when the heart beats. In this case, the systolic pressure is 102 mm Hg. The nurse should clarify if this is the correct systolic blood pressure measurement, especially if there is any doubt or inconsistency in the documentation.

Choice B rationale:

The position of the client, as mentioned in the documentation ("client sitting up in a chair"), is adequately described. There is no need to clarify this aspect of the documentation.

Choice C rationale:

The unit of measurement is clearly indicated as "mm Hg" in the documentation, so there is no ambiguity regarding the unit of measurement. There is no need to clarify this aspect.

Choice D rationale:

The location of the blood pressure cuff is not mentioned in the documentation. However, the key issue in this scenario is the accuracy of the systolic blood pressure measurement (the 102 mm Hg value). Therefore, the nurse should first address the systolic blood pressure measurement before clarifying other details.

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose? To calculate the correct dose in milliliters (mL), you can use the formula: Desired Dose (in mg) = Available Dose (in mg/mL) * Volume (in mL) Desired Dose (in mg) = 40 mg Available Dose (in mg/mL) = 10 mg/1 mL Now, plug these values into the formula: Volume (in mL) = 40 mg / 10 mg/1 mL Volume (in mL) = 4 mL The nurse should administer 4 mL of furosemide per dose.