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Mary Thomas presents with red, teary eyes, a runny nose, and a stuffy head. What nursing orders would be recommended?
- A. Antihistamines, aspirin, and cough syrup
- B. Increased fluids, steam inhalation, and rest
- C. Aspirin, cough syrup, and increased fluids
- D. Auscultation and percussion of the chest
Correct Answer: B
Rationale: Hydration, steam inhalation, and rest help alleviate symptoms and promote recovery.
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When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.
When planning care, what factors should the nurse consider when utilizing evidence-based practice (EBP)? (Select ONE that does not apply)
- A. Cost-saving measures
- B. Nurse's expertise
- C. Client preferences
- D. Research findings
Correct Answer: A
Rationale: The correct answer is A: Cost-saving measures. When utilizing evidence-based practice, the nurse should prioritize providing care based on research findings, considering client preferences, and leveraging their expertise. Cost-saving measures should not be the primary factor influencing care decisions as the focus should be on delivering the most effective and appropriate care based on evidence. Ignoring research findings, client preferences, or the nurse's expertise could compromise the quality of care provided. Thus, cost-saving measures are not a factor to consider when planning care with evidence-based practice.
Match the following data with the assessment technique used to obtain the information.
- A. Normal blood flow through arteries
- B. Abnormal blood flow in carotid artery
- C. Tympany of the abdomen
- D. Pitting edema
Correct Answer: D
Rationale: The correct match depends on the technique: Auscultation detects normal/abnormal blood flow, percussion reveals tympany, and palpation identifies pitting edema.
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary.
Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.
What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a barrel chest, which is often associated with chronic breathing problems like chronic obstructive pulmonary disease (COPD). Chronic breathing problems can lead to this specific chest shape due to increased lung volume. Choice A is incorrect as it does not directly relate to the physical assessment findings. Choice C is incorrect as it focuses on exercise habits rather than the client's current health status. Choice D is incorrect as it does not address the potential underlying health issue indicated by the chest measurements.