Nokea
A deathly ill patient from a culture different than the nurse’s is admitted. Which question is appropriate to help the nurse provide culturally competent care?
- A. “If you die
- B. will you want an autopsy?”
- C. “Are you interested in learning about palliative or hospice care?”
- D. “Do you have any preferences for what happens if you are dying?”
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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It is estimated that the population of people aged 65 or older in United States will increase to:
- A. 13%
- B. 20%
- C. 25%
- D. 38%
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
- A. Do you have trouble affording your medications?
- B. Most people with hypertension do not have symptoms.
- C. You are lucky; most people get severe morning headaches.
- D. You need to take your medicine or you will get kidney failure.
Correct Answer: B
Rationale: Step-by-step rationale:
1. Choice B is correct because it educates the client that hypertension often presents without symptoms.
2. Lack of symptoms does not mean the condition is not serious.
3. This response promotes understanding and adherence to medication.
4. Choices A, C, and D are incorrect as they do not address the main issue of hypertension being asymptomatic.
A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?
- A. Fremitus
- B. Hyperresonance
- C. Dullness on percussion
- D. Decreased tactile fremitus
Correct Answer: C
Rationale: The correct answer is C: Dullness on percussion. Pneumonia is characterized by consolidation of lung tissue, causing dullness on percussion due to increased density. Fremitus (A) and tactile fremitus (D) are decreased in conditions like pleural effusion or pneumothorax, not pneumonia. Hyperresonance (B) is associated with conditions like emphysema, not pneumonia. In pneumonia, the affected area is consolidated, leading to dullness on percussion.
A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?
- A. Assistance with activities of daily living.
- B. Daily physical therapy activities.
- C. Oxygen therapy at 2 liters per nasal cannula.
- D. Complete bedrest with frequent repositioning.
Correct Answer: A
Rationale: The correct answer is A: Assistance with activities of daily living. Class III dyspnea signifies moderate exertion causing symptoms. Therefore, the client may need help with daily activities to conserve energy. Daily physical therapy (B) may be too strenuous. Oxygen therapy (C) may not be necessary at this point. Complete bedrest (D) can lead to deconditioning.
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically adjust the oxygen flow rate.
- C. Remove the tubing from the client's nose.
- D. Turn the client every 2 hours or as needed.
Correct Answer: A
Rationale: The correct answer is A - Apply water-soluble ointment to nares and lips. This is an appropriate comfort measure that can be safely delegated to UAP as it helps prevent dryness and irritation caused by the oxygen flow. UAP can apply ointment without adjusting the oxygen flow rate (B), which should be done by licensed staff. Removing the tubing (C) can disrupt oxygen delivery. Turning the client (D) is important for preventing pressure ulcers but is not directly related to oxygen therapy comfort.