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A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?
- A. Ask the patient to take deep breaths
- B. Have the patient sit upright
- C. Examine for symmetry
- D. Ask the patient to lie flat and breathe normally
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients.
A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately.
B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds.
C: Examining for symmetry is important but not directly related to the optimal position for auscultation.
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Which of the following statements best describes the purpose of a health history?
- A. To provide an opportunity for interaction between patient and nurse
- B. To provide a form for obtaining the patient's biographical information
- C. To document the normal and abnormal findings of a physical assessment
- D. To provide a database of subjective information about the patient's past and current health
Correct Answer: D
Rationale: The correct answer is D because a health history aims to gather subjective information about a patient's past and current health. It helps in understanding the patient's health concerns, medical history, lifestyle factors, and other relevant information. By collecting this data, healthcare providers can make informed decisions regarding the patient's care. Option A is incorrect as the purpose is more than just interaction. Option B is incorrect as it focuses solely on biographical information. Option C is incorrect as it pertains to physical assessment findings, not subjective health information.
A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?
- A. Managing pain.
- B. Monitoring for infection.
- C. Preventing deep vein thrombosis (DVT).
- D. Ensuring proper positioning.
Correct Answer: C
Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.
The nurse notices that the patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:
- A. Bulla.
- B. Wheal.
- C. Nodule.
- D. Papule.
Correct Answer: D
Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites.
A: Bulla is a large fluid-filled blister, not a solid lesion.
B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction.
C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.
A nurse is providing education to a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following lifestyle changes?
- A. Quitting smoking.
- B. Increasing fluid intake.
- C. Increasing physical activity.
- D. Taking over-the-counter cold medications.
Correct Answer: A
Rationale: The correct answer is A: Quitting smoking. Smoking is the most important lifestyle change for a patient with COPD as it is the primary cause of the disease and continues to worsen symptoms. Quitting smoking can slow down the progression of COPD, decrease exacerbations, and improve overall lung function.
Summary of other choices:
B: Increasing fluid intake - While staying hydrated is important for overall health, it is not the top priority for a patient with COPD.
C: Increasing physical activity - Exercise is beneficial for COPD patients, but quitting smoking takes precedence as it directly impacts the disease progression.
D: Taking over-the-counter cold medications - Cold medications may provide temporary relief for symptoms, but they do not address the underlying cause of COPD which is smoking.
A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates the need for further education?
- A. I will check my blood sugar regularly.
- B. I will take my insulin only when my blood sugar is high.
- C. I will eat a balanced diet and exercise regularly.
- D. I will report any signs of infection to my healthcare provider.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Taking insulin only when blood sugar is high can lead to uncontrolled levels.
2. Regular insulin dosing is essential for diabetes management.
3. Monitoring blood sugar regularly helps in adjusting insulin doses.
4. Eating a balanced diet and exercising are key components of diabetes management.
5. Reporting signs of infection is crucial due to diabetes-related complications.