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A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following signs of an asthma exacerbation?
- A. Decreased work of breathing.
- B. Increased wheezing and shortness of breath.
- C. Improved oxygen saturation.
- D. Decreased sputum production.
Correct Answer: B
Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.
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A patient who is recovering from surgery is experiencing nauseWhat is the nurse's best action?
- A. Offer the patient clear fluids immediately.
- B. Administer an antiemetic as prescribed.
- C. Wait for the nausea to subside on its own.
- D. Assess the patient's vital signs to check for a potential infection.
Correct Answer: B
Rationale: The correct answer is B: Administer an antiemetic as prescribed. Administering an antiemetic helps alleviate nausea and vomiting, providing relief to the patient. This action is based on evidence-based practice and helps improve the patient's comfort and well-being. Offering clear fluids immediately (choice A) may exacerbate nausea. Waiting for the nausea to subside on its own (choice C) may prolong the patient's discomfort. Assessing vital signs (choice D) is important but may not directly address the immediate symptom of nausea.
The nurse is assessing a new patient who has recently immigrated to CanadWhich of the following questions is appropriate to add to the health history questionnaire?
- A. "Why did you come to Canada?"
- B. "When did you come to Canada, and from which country?"
- C. "What made you leave your home country?"
- D. "Are you planning to return to your home country?"
Correct Answer: B
Rationale: The correct answer is B. It is important to know when the patient immigrated and from which country for understanding potential health risks, cultural factors, and access to healthcare. Choice A is too broad and may not yield relevant health information. Choice C focuses on personal reasons for leaving the home country, which may not be medically relevant. Choice D is forward-looking and may not be necessary for the initial assessment.
When performing a physical assessment, the first technique the nurse will use is:
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: B
Rationale: The correct answer is B: Inspection. This is because visual observation is typically the initial step in a physical assessment to gather information about the patient's overall appearance, skin color, posture, and any obvious abnormalities. Palpation (A) involves touching and feeling for abnormalities, which usually follows inspection. Percussion (C) is the technique of tapping on the body to assess underlying structures, and auscultation (D) is listening to sounds produced by the body, both of which typically come after inspection and palpation. Inspecting the patient first allows the nurse to establish a baseline before moving on to more detailed assessment techniques.
When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?
- A. Identifying existing levels of wellness
- B. Evaluating previous problems and goals
- C. Identifying potential problems the individual may develop
- D. Focusing on strengths and reflecting an individual's transition to higher levels of wellness
Correct Answer: C
Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Respiratory failure.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD have impaired lung function, making them at risk for respiratory failure due to inadequate oxygenation. This can occur due to exacerbation of COPD, infections, or other factors. Monitoring for signs of respiratory distress is crucial.
A: Pneumonia - While patients with COPD are at higher risk for pneumonia due to impaired lung function, respiratory failure is a more immediate and critical complication to monitor for in this scenario.
C: Hypoglycemia - COPD does not directly increase the risk of hypoglycemia, so monitoring for this complication is not a priority in this case.
D: Hypertension - Although some patients with COPD may have hypertension, it is not a common complication directly related to COPD. Monitoring for respiratory failure is more essential in this situation.