The nurse is caring for a patient with sepsis. The nurse includes potential complication: septic shock in the plan of care. Why is this nursing diagnosis considered to be a collaborative problem?
The patient has a history of noncompliance with prescribed therapeutic regimens.
The patient must be closely monitored in an intensive care unit.
Prevention of septic shock is not a measurable patient outcome.
Both nursing and physician-prescribed interventions are required.
The Correct Answer is D
Choice A reason: This is an incorrect choice because the patient has a history of noncompliance with prescribed therapeutic regimens is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's history of noncompliance is not related to the nature of the problem or the type of intervention required.
Choice B reason: This is an incorrect choice because the patient must be closely monitored in an intensive care unit is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's need for close monitoring is not related to the nature of the problem or the type of intervention required.
Choice C reason: This is an incorrect choice because prevention of septic shock is not a measurable patient outcome is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The measurability of the patient outcome is not related to the nature of the problem or the type of intervention required.
Choice D reason: This is the correct choice because both nursing and physician-prescribed interventions are required is a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The problem of septic shock is a complex and life-threatening condition that involves multiple organ systems and requires both medical and nursing interventions to prevent, treat, and monitor the patient's status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because calling the operator to activate the fire alarm is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Calling the operator to activate the fire alarm is an important action to alert the fire department and the other staff and patients, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before calling for help.
Choice B reason: This is an incorrect choice because closing the door to contain the fire is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Closing the door to contain the fire is a helpful action to prevent the fire from spreading to other areas, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before containing the fire.
Choice C reason: This is an incorrect choice because utilizing a fire extinguisher to put out the fire is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Utilizing a fire extinguisher to put out the fire is a possible action to control the fire, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before attempting to extinguish the fire.
Choice D reason: This is the correct choice because removing the patient to a safe area is the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Removing the patient to a safe area is the most urgent and priority action to protect the patient from the fire, smoke, and heat. The nurse should first assess the patient for any injuries or burns, and then move the patient to a safe and clear location away from the fire.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Wiping up the liquid with paper towels and gloves can spread the mercury droplets and increase the risk of exposure. Mercury can also penetrate through nitrile gloves and cause skin irritation.
Choice B reason: This is incorrect. Disinfecting the area with chlorine bleach can create toxic vapours that can harm the respiratory system. Chlorine bleach is not effective in removing mercury from the surface.
Choice C reason: This is incorrect. Contacting the housekeeping staff to mop up the liquid can delay the proper clean-up and disposal of mercury. Mopping can also disperse the mercury droplets and contaminate the mop and the water.
Choice D reason: This is correct. Consulting the agency’s materials safety data sheets (MSDS) is the priority action of the nurse. MSDS provide information on the hazards, precautions, and procedures for handling and disposing of mercury. The nurse should follow the MSDS guidelines and use the appropriate equipment and methods to clean up the spill.
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