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After coronary artery bypass graft surgery, a male client is admitted to the coronary care unit. Which nursing diagnosis is of the highest priority?
- A. Ineffective breathing pattern.
- B. Impaired gas exchange.
- C. Acute pain.
- D. Risk for infection.
Correct Answer: B
Rationale: Impaired gas exchange is the highest priority nursing diagnosis because it directly impacts the client's oxygenation. Following coronary artery bypass graft surgery, ensuring adequate oxygen exchange is crucial for the client's recovery. Ineffective breathing pattern, although important, may not be as critical as impaired gas exchange in the immediate postoperative period. Acute pain, while significant, can be managed effectively with appropriate interventions and is not as emergent as addressing impaired gas exchange. Risk for infection is also a valid concern post-surgery, but ensuring optimal gas exchange takes precedence to prevent complications associated with inadequate oxygenation.
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A nurse is planning a community health fair to promote cancer awareness. Which activity should be included to best engage participants?
- A. free cancer screenings
- B. lectures on cancer prevention
- C. distribution of educational materials
- D. testimonials from cancer survivors
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
- A. Administer the dose as prescribed.
- B. Hold the medication.
- C. Call the healthcare provider.
- D. Repeat the vital signs in 30 minutes.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
- A. Client appears anxious.
- B. Client's skin is warm and dry.
- C. S1 murmur auscultated in supine position.
- D. Client is resting quietly.
Correct Answer: C
Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.
The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning effectively?
- A. Continuous bubbling in the water-seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. No fluctuation (tidaling) in the water-seal chamber.
- D. Drainage of clear, pale yellow fluid from the chest tube.
Correct Answer: B
Rationale: Intermittent bubbling in the suction control chamber is the correct observation indicating effective functioning of the chest tube. This bubbling signifies that the suction system is working correctly and maintaining the desired negative pressure in the pleural space. Continuous bubbling in the water-seal chamber suggests an air leak, which is not a normal finding. No fluctuation (tidaling) in the water-seal chamber may indicate a blockage or lack of communication between the pleural space and the water-seal, which is not ideal. Drainage of clear, pale yellow fluid from the chest tube is a normal finding, but it does not specifically indicate the effectiveness of the chest tube function.
The school nurse who is reviewing immunization records of students who will start kindergarten within the next month notes that most of the students have only received one dose of the measles, mumps, rubella (MMR) vaccine. Which intervention should the nurse implement?
- A. note in the student records that the second dose of the MMR vaccine should be administered prior to entering first grade
- B. send notices home with the children on the first day of class advising that MMR vaccine series must be completed
- C. contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year
- D. speak at the next parent teacher association meeting to teach parents the benefits of immunizing their children
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.