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How will recognizing that clients have different perceptions of time assist the nurse to provide more sensitive care?
- A. Adapting care plans to accommodate varying time perspectives.
- B. Enforcing strict schedules regardless of cultural differences.
- C. Ignoring time-related preferences.
- D. None of the above.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the client's oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.
A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Pain at insertion site
- D. Sudden onset of shortness of breath
Correct Answer: B
Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent further complications. The other choices are incorrect because:
A: Production of pink sputum may indicate blood-tinged sputum, which could be a sign of minor bleeding but does not require immediate intervention.
C: Pain at insertion site is common after chest tube insertion and can be managed with pain medication, not necessarily requiring immediate intervention.
D: Sudden onset of shortness of breath could indicate various issues, including pneumothorax, but tracheal deviation is a more specific and urgent sign that requires immediate attention.
Mrs. Brown asks about the difference between wide- and narrow-angle glaucoma. Which of the following responses would be most appropriate?
- A. With wide-angle glaucoma there is a minimal increase in ocular pressure.
- B. Wide-angle glaucoma is usually asymptomatic.
- C. Complications from narrow-angle glaucoma are less severe than those from wide-angle glaucoma.
- D. Narrow-angle glaucoma is usually asymptomatic.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which procedures are done for curative purposes (select all that apply)?
- A. Gastroscopy
- B. Rhinoplasty
- C. Tracheotomy
- D. Hysterectomy, Herniorrhaphy
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease is being taught by a nurse. Which nutritional information should the nurse include in the teaching? (SATA)
- A. Avoid drinking fluids just before and during meals.
- B. Rest before meals if you have dyspnea.
- C. Have about six small meals a day.
- D. Eat high-fiber foods to promote gastric emptying.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. High-fiber foods promote gastric emptying, reducing the risk of bloating and discomfort in COPD patients.
2. COPD patients may experience difficulty breathing, leading to decreased physical activity and slower digestion.
3. Consuming high-fiber foods helps regulate bowel movements and prevents constipation, common in COPD patients.
Summary of Incorrect Choices:
A: Avoiding fluids just before and during meals is not specific to COPD patients and may not directly address their nutritional needs.
B: Resting before meals if experiencing dyspnea may be helpful, but it does not address specific nutritional information.
C: Having six small meals a day may be beneficial for some COPD patients, but it does not directly address the importance of high-fiber foods for promoting gastric emptying.