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A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
- A. Place the client in semi-Fowler's position
- B. Have the client rest an arm across the abdomen
- C. Observe one full respiratory cycle before counting the rate
- D. Count the rate for one minute if it is regular
- E. Count & report any sighs the client demonstrates
Correct Answer: A, B, C
Rationale: The correct guidelines for measuring a client's respiratory rate are to place the client in semi-Fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle before counting the rate. Placing the client in semi-Fowler's position helps with optimal lung expansion and breathing efficiency. Having the client rest an arm across the abdomen can help the nurse visualize the rise and fall of the chest more clearly. Observing one full respiratory cycle before counting the rate ensures accuracy in counting. These guidelines are essential for obtaining an accurate respiratory rate. Choices D and E are incorrect as counting for one minute is unnecessary if the rate is regular, and counting and reporting sighs is not part of the respiratory rate measurement process.
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A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique?
- A. I will straighten my ear canal by pulling my ear down & back.
- B. I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops.
- C. I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.
- D. After the drops are in, I will place a cotton ball all the way into my ear canal.
Correct Answer: B
Rationale: The correct answer is B: "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops." This statement indicates understanding of the proper technique because applying pressure to the tragus helps the ear drops to reach the ear canal. The tragus is a small cartilaginous projection in front of the ear canal that, when pressed, helps to facilitate the passage of the drops into the ear. This action ensures proper distribution of the medication for effective treatment.
Other choices are incorrect:
A: Pulling the ear down and back is a technique used for administering ear drops in children, not adults.
C: Inserting the nozzle snug into the ear can cause injury to the ear canal and eardrum.
D: Placing a cotton ball all the way into the ear canal can prevent the drops from reaching the ear canal and may cause blockage.
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by the body's inability to regulate its temperature due to prolonged exposure to high temperatures. This leads to excessive sweating and dehydration, resulting in a drop in blood pressure (hypotension). Bradycardia (B) is a slow heart rate, which is not typically seen in heat stroke. Clammy skin (C) is common in heat exhaustion, not heat stroke. Bradypnea (D) is slow breathing, which is not a common sign of heat stroke. Therefore, hypotension is the most appropriate choice as it aligns with the pathophysiology of heat stroke.
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve?
- A. Fat
- B. Protein
- C. Glycogen
- D. Carbohydrates
Correct Answer: D
Rationale: The correct answer is D: Carbohydrates. Carbohydrates are the body's priority energy reserve because they are the primary source of energy for the body, especially during high-intensity activities like sports. When consumed, carbohydrates are broken down into glucose, which is used for immediate energy or stored as glycogen in muscles and the liver for later use. Fat is a long-term energy reserve but is not as readily accessible as carbohydrates for quick energy. Protein is primarily used for building and repairing tissues, not as a main energy source. Glycogen is a stored form of carbohydrates in the body, not the primary energy reserve.
A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
- A. I'll wait to use the device until it's absolutely necessary.
- B. I'll be careful about pushing the button so I don't get an overdose.
- C. I should tell the nurse if the pain doesn't stop after I use this device.
- D. I will ask my son to push the dose button when I am sleeping.
Correct Answer: C
Rationale: The correct answer is C because the client demonstrating understanding of using the PCA infusion device should know to communicate with the nurse if the pain persists after using the device. This indicates the client's awareness of the importance of monitoring pain levels and seeking help if needed. Choice A does not demonstrate understanding of the device's purpose or functionality. Choice B shows awareness of the risk of overdose but not necessarily how to use the device correctly. Choice D is incorrect as the client should be the one responsible for administering the medication through the PCA device.
A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:
- A. Some clients exaggerate their level of pain
- B. Pain must have an identifiable source to justify the use of opioids.
- C. Objective data are essential in assessing pain
- D. Pain is whatever the client says it is.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Pain is a subjective experience: Pain perception varies among individuals, making it crucial to consider the client's own description.
2. Client-centered care: Acknowledging the client's self-report of pain is essential in providing effective and compassionate care.
3. Holistic approach: Recognizing the client's perspective on pain helps in addressing their physical, emotional, and psychological needs.
4. Trust and rapport: Valuing the client's self-assessment of pain fosters a trusting relationship between the nurse and the client.
5. Evidence-based practice: Research supports that self-reporting of pain is the most reliable indicator of pain intensity.
Summary:
- Choice A is incorrect as assuming clients exaggerate pain undermines their credibility and may lead to inadequate pain management.
- Choice B is incorrect as pain is not always identifiable, and opioids may be justified based on the client's report.
- Choice C is incorrect as relying solely on objective data overlooks the