Nokea
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.
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Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?
- A. Opening the patient's window to the outside environment
- B. Turning on the patient's room ventilator
- C. Opening the door of the patient's room leading into the hospital corridor
- D. Failing to wear gloves when administering a bed bath
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare provider reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3-month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The healthcare provider could be charged with:
- A. Defamation
- B. Assault
- C. Battery
- D. Malpractice
Correct Answer: D
Rationale: The scenario described involves a breach of duty by the healthcare provider to properly supervise the infant, resulting in harm. This failure to meet the standard of care falls under the category of malpractice, which refers to professional negligence or misconduct. Malpractice specifically applies to situations where a healthcare provider's actions or omissions deviate from the accepted standard of care, causing harm to a patient. In this case, the nurse's lack of supervision leading to the infant falling off the scale and sustaining a skull fracture would be considered malpractice.
Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
- A. Side rails are ineffective
- B. Side rails should not be used
- C. Side rails are a deterrent that prevents a patient from falling out of bed
- D. Side rails are a reminder to a patient not to get out of bed
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:
- A. Ineffective airway clearance related to thick, tenacious secretions.
- B. Ineffective airway clearance related to dry, hacking cough.
- C. Ineffective individual coping with COPD.
- D. Pain related to immobilization of affected leg.
Correct Answer: A
Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.
Palpating the midclavicular line is the correct technique for assessing
- A. Baseline vital signs
- B. Systolic blood pressure
- C. Respiratory rate
- D. Apical pulse
Correct Answer: D
Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.