101.

The two nursing diagnoses that have the highest priority that the nurse
can assign are Ineffective airway clearance and Ineffective breathing pattern.
RATIONALE: An ineffective breathing pattern is defined as inspiration
and/or expiration that does not provide adequate oxygenation. This
diagnosis is related to the observed rate and depth of breathing, as
well as abnormal chest expansion, and accessory muscle use that
results in a breathing pattern that does not supply adequate
ventilation to the body. The ABCs; airway, breathing, and circulation,
are the highest priority of nurses in caring for patients. An ineffective
breathing pattern can arise from an array of causes and can occur
suddenly. Nurses must be vigilant in observing acute changes and
preventing the deterioration of patients and the possibility
of respiratory failure.

102. A subjective sign that a sitz bath has been effective is the patient’s
expression of decreased pain or discomfort.
RATIONALE: A sitz bath is a warm, shallow bath people sit in to cleanse
the perineum, which is the space between the rectum and
the vulva or scrotum. A sitz bath can also provide relief from pain
or itching in the genital area. A person can take a sitz bath with or without
medication. Many people use only water without any additives, but some
people may add Epsom salt, vinegar, or baking soda to their baths. A
doctor may prescribe a sitz bath with medication for different conditions.
You can take a sitz bath in a bathtub or with a small plastic tub that fits
over the toilet. Fill the tub with enough water to cover the perineum. Then,
sit in the tub for 15 to 20 minutes.

103. For the nursing diagnosis Deficient diversional activity to be valid, the
patient must state that he’s “bored,” that he has “nothing to do,” or words to
that effect.

104. The most appropriate nursing diagnosis for an individual who doesn’t
speak English is Impaired verbal communication related to inability to speak
dominant language (English).

RATIONALE: Nursing Diagnosis: Impaired Verbal Communication related to

cultural incongruence as evidenced by inability to speak the language of the
caregiver. Overall Goal: The patient will use effective communication
techniques. SMART Expected Outcome: Mrs. Rosas will utilize interpreter
services in order to receive information and express needs throughout her
hospitalization. Planning and Implementing Nursing Interventions:
 The nurse will provide patient with interpreter services in order to facilitate
patient communication. In-person interpreter or language line telephone
services will be utilized to ensure that the patient receives information about
her care. The nurse will eliminate distractions such as the television, hallway
noise, etc., to decrease sources of additional stimuli in the communication
experience. The nurse will communicate directly with the patient, utilizing
appropriate eye contact, and nonverbal cues to enhance the communication
experience.

105. The family of a patient who has been diagnosed as hearing impaired
should be instructed to face the individual when they speak to him.
RATIONALE: Successful communication requires the
efforts of all people involved in a conversation. Even
when the person with hearing loss utilizes hearing
aids and active listening strategies, it is crucial that
others involved in the communication process
consistently use good communication strategies,
including the following:

 Face the hearing-impaired person directly, on the

same level and in good light whenever possible.
Position yourself so that the light is shining on the
speaker's face, not in the eyes of the listener.
 Do not talk from another room. Not being able to see
each other when talking is a common reason people
have difficulty understanding what is said.
 Speak clearly, slowly, distinctly, but naturally, without
shouting or exaggerating mouth movements. Shouting
distorts the sound of speech and may make speech
reading more difficult.
 Say the person's name before beginning a
conversation. This gives the listener a chance to focus
attention and reduces the chance of missing words at
the beginning of the conversation.
 Avoid talking too rapidly or using sentences that are
too complex. Slow down a little, pause between
sentences or phrases, and wait to make sure you have
been understood before going on.
 Keep your hands away from your face while talking. If
you are eating, chewing, smoking, etc. while talking,
your speech will be more difficult to understand.
 Beards and moustaches can also interfere with the
ability of the hearing impaired to speech read.
 If the hearing-impaired listener hears better in one ear
than the other, try to make a point of remembering
which ear is better so that you will know where to
position yourself.
 Be aware of possible distortion of sounds for the
hearing-impaired person. They may hear your voice,
but still may have difficulty understanding some
words.
 Most hearing-impaired people have greater difficulty
understanding speech when there is background
noise. Try to minimize extraneous noise when talking.
 Some people with hearing loss are very sensitive to
loud sounds. This reduced tolerance for loud sounds is
not uncommon. Avoid situations where there will be
loud sounds when possible.

106. Before instilling medication into the ear of a patient who is up to age 3,
the nurse should pull the pinna down and back to straighten the eustachian
tube.
RATIONALE: Administering ear medication is a fundamental skill that requires the
nurse to either irrigate the ear canal or carefully place drops into the ear canal. Be sure to
administer the medication as ordered and in the correct ear. While performing the
procedure, educate the patient on proper techniques for home care. To straighten out the
ear canal in children less than 3 years of age, pull the Pinna/Auricle (outer part of the ear)
back and downwards. This method administers a drop more accurately into the ear by
permitting gravity to pull it down. “Child” has the letter “D” for Downward. For children,
the pinna should be pulled straight back, and for infants, it should be pulled
down and back. This movement straightens the auditory canal and prepares it
for instillation. The nurse should squeeze the bottle so that the drops of
medication fall onto the side of the auditory canal and not directly onto the
tympanic membrane. The medication should run towards the tympanic
membrane after it is instilled.

107. To prevent injury to the cornea when administering eyedrops, the nurse
should waste the first drop and instill the drug in the lower conjunctival sac.
RATIONALE: Eye drops are administered for a local effect on the eye.
Examples of eye drop medications include antibiotic drops for conjunctivitis,
glaucoma medication to reduce intraocular pressure, and saline drops to
relieve dry eyes. The amount of drops to administer per eye is indicated on
the provider order. When instilling eye drops, the nurse should perform hand
hygiene, apply gloves, and check the same rights of medication administration
as done with other types of medication. Prior to administration of eye
medication, the patient’s eyes should be assessed for new or unusual
redness or drainage. If discharge is present, the eyelids should be cleansed
with gauze saturated with warm water or normal saline to remove any dirt or
debris that could be carried into the eye during instillation. When cleaning the
eyelids, the nurse should clean from the inner canthus toward the outer
canthus so as not to introduce debris or dirt into the lacrimal ducts that could
cause an infection. A new gauze pad is used for each stroke. The nurse
should remove gloves after cleansing, perform hand hygiene, and apply new
gloves prior to medication administration.

108. After administering eye ointment, the nurse should twist the medication
tube to detach the ointment.
RATIONALE: When administering the drops, the patient should be instructed
to tilt their head backwards or be positioned in a supine position with their
head on a pillow looking up. When the cap of the medication is removed, it
should be placed on a clean surface with care taken to keep the inside of the
cap sterile and to not contaminate the dropper tip. The patient should look up
and away while the nurse gently uses pressure to pull the lower lid down and
expose the lower conjunctival sac. By holding the dropper close to the sac
without touching it, the nurse should squeeze the bottle and allow the drop to
fall into the sac, taking care to not touch the dropper to the eye. After the eye
drop has been instilled, the patient should close their eye. The nurse should
apply gentle pressure to the inner canthus, when appropriate, to prevent the
medication from entering the lacrimal duct and causing a possible systemic
reaction to the medication.

109. When the nurse removes gloves and a mask, she should remove the
gloves first. They are soiled and are likely to contain pathogens.
RATIONALE: Since healthcare personnel hands have the
greatest potential to become contaminated, gloves are usually
removed first. The face shield or goggles are often the next to
be removed as they may interfere with removal of other PPE,
followed by the gown and then face mask or respirator. Hand
hygiene should be performed following glove removal to ensure the hands will
not carry potentially infectious agents that might have penetrated through
unrecognized tears or contaminated the hands during glove removal.

110. Crutches should be placed 6″ (15.2 cm) in front of the patient and 6″ to
the side to form a tripod arrangement.
RATIONALE: Have the patient begin in the tripod position, with the patient’s
feet parallel and the crutches 15 centimeters (or 6 inches) to the sides and 15
centimeters (or 6 inches) in front of the patient’s feet. ii. Stand behind the
patient and slightly to the side, holding the gait belt firmly in one hand. Instruct
the patient to move the right crutch forward 10 to 15 centimeters (4 to 6
inches), then move his or her left foot forward until it is parallel with the left
crutch. Next, have the patient move the left crutch forward 10 to 15
centimeters (4 to 6 inches), then move his or her right foot forward until it is
parallel with the right crutch.
111. Listening is the most effective communication technique.
RATIONALE: Listening is the learned process of receiving,
interpreting, recalling, evaluating, and responding to verbal and
nonverbal messages. We begin to engage with the listening process
long before we engage in any recognizable verbal or nonverbal
communication. Listening also has implications for our personal lives
and relationships. We shouldn’t underestimate the power of listening
to make someone else feel better and to open our perceptual field to
new sources of information. Empathetic listening can help us expand
our self and social awareness by learning from other people’s
experiences and by helping us take on different perspectives.

112. Before teaching any procedure to a patient, the nurse must assess the
patient’s current knowledge and willingness to learn.
RATIONALE: This is to assess if they are willing to cooperate in the
procedure. They have the right to decide on their own and we nurses should
respect that. Being healthcare provider, we are responsible for educating the
patient about their condition and the treatment.

113. Process recording is a method of evaluating one’s communication

effectiveness.
RATIONALE: Process recording is a tool used by the HEALTHCARE provider
to examine the dynamics of a particular interaction in time. The process
recording is an excellent teaching device for learning and refining interviewing
and intervention skills. The process recording helps us conceptualize and
organize ongoing activities with client systems, to clarify the purpose of the
interview or intervention, to improve written expression, to identify strengths
and weaknesses, and to improve selfawareness (Urbanowski & Dwyer, 1988).

114. When feeding an elderly patient, the nurse should limit high-
carbohydrate foods because of the risk of glucose intolerance.
RATIONALE: The mechanism of age-related glucose intolerance is not yet
completely clear. The interaction of many factors associated with aging likely
contributes to the alteration of glucose tolerance in this population. These
factors include increased adiposity, decreased physical activity, medications,
coexisting illnesses, and insulin secretory defects associated with the aging
processes. Insensitivity to the actions of insulin at the postreceptor level,
inadequate secretion of insulin and decreased hepatic sensitivity to insulin's
action in suppressing glucose output also occur with advancing age.