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In what patient situations would a comprehensive assessment be performed (select all that apply)?
- A. Complaints of chest pain
- B. On initial admission to the telemetry unit
- C. On initial evaluation by the home health nurse
- D. The patient is found lying on the floor and is unresponsive
Correct Answer: B
Rationale: The correct answers are 'On initial admission to the telemetry unit,' 'On initial evaluation by the home health nurse,' and 'On arrival in the surgery holding area of the operating room.' Comprehensive assessments are necessary for baseline data collection in new or complex cases.
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Joan is apprehensive about undergoing bronchoscopy. You respond by saying
- A. The thought of this procedure seems to be disturbing you. You will be sleeping during this procedure. I will ask your physician to visit you again and answer any questions that you might have regarding the procedure.
- B. Your physician has performed this procedure frequently.
- C. I had it performed 3 years ago and I was fine.
- D. You would not feel a thing. You will be fine.
Correct Answer: A
Rationale: Option A provides emotional support, reassurance, and an opportunity for further clarification, which is essential in reducing patient anxiety.
You are caring for a patient with Sophaged cancer. Which task could be delegated to the nursing assistant?
- A. Assist the patient with oral hygiene.
- B. Observe the patient's response to feedings.
- C. Facilitate expression of grief or anxiety.
- D. Initiate daily weights.
Correct Answer: A
Rationale: Oral hygiene is a basic care task that can be safely performed by a nursing assistant, while the other options require more advanced clinical judgment.
A patient with a history of pulmonary embolism asks how to lower the risk of experiencing another pulmonary embolism. You respond by saying
- A. Take vitamin K with heparin.
- B. Avoid confined spaces.
- C. Avoid sitting and standing for too long and do not cross your legs.
- D. Jog 5 miles each day.
Correct Answer: C
Rationale: Prolonged immobility increases the risk of pulmonary embolism.
Which of the following is a definitive sign of pregnancy?
- A. Amenorrhea
- B. Positive hCG
- C. Morning sickness
- D. Fetal heart sounds
Correct Answer: D
Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.
A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?
- A. Stridor
- B. Copious oral secretions
- C. Hoarseness
- D. Sore throat
Correct Answer: A
Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, harsh respiratory sound that indicates airway obstruction, which can be life-threatening post endotracheal tube removal. Copious oral secretions (B), hoarseness (C), and sore throat (D) are common after endotracheal tube removal but do not indicate immediate airway compromise. Reporting stridor is crucial for prompt intervention to prevent respiratory distress.