Nokea
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
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A nurse is collecting data from an adolescent client. Which of the following behaviors should the nurse expect an adolescent who has achieved successful resolution of the developmental tasks of identity vs. role confusion to exhibit?
- A. Expresses her opinions
- B. Uses time effectively
- C. Starts and completes a task
- D. Establishes a close relationship with another person
Correct Answer: A
Rationale: The correct answer is A: Expresses her opinions. Adolescents who have successfully resolved the developmental task of identity vs. role confusion are more likely to express their opinions confidently and assertively as they have a clear sense of self and have developed their own identity. This behavior reflects their ability to articulate their thoughts and beliefs, showing autonomy and independence.
Summary of other choices:
B: Using time effectively is a good skill but not directly related to resolving identity vs. role confusion.
C: Starting and completing tasks is important, but not indicative of resolving identity issues.
D: Establishing close relationships is important, but it is not the primary behavior associated with resolving identity vs. role confusion.
A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Turn and position each client every 2 hr.
- B. Identify the clients at greatest risk for development of pressure ulcers.
- C. Use a barrier cream when performing perineal care.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: B
Rationale: The correct answer is B: Identify the clients at greatest risk for development of pressure ulcers. This is the priority because it allows for targeted interventions to be implemented for those most vulnerable, maximizing resources and preventing potential harm. Turning and positioning clients, using barrier creams, and ensuring adequate nutrition are all important aspects of pressure ulcer prevention, but they should be tailored based on individual risk assessment. Supervising nutritional intake is crucial, but not the immediate priority in preventing pressure ulcers. Identifying high-risk clients allows for proactive measures to be taken, making it the most critical step in meeting the National Safety Goal.
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of a latex allergy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply an elastic bandage to a cut.
- B. When cleaning, I like to use dishwashing gloves.
- C. On my son's birthday I plan to buy balloons.
- D. I will use ink pens for writing.
Correct Answer: D
Rationale: The correct answer is D: "I will use ink pens for writing." This statement indicates an understanding of the teaching because ink pens do not contain latex, thus reducing the risk of exposure for someone with a latex allergy. Elastic bandages (choice A) typically contain latex, dishwashing gloves (choice B) may contain latex, and balloons (choice C) are commonly made of latex, all of which could trigger an allergic reaction. Therefore, using ink pens for writing is the safest choice to avoid latex exposure.