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.
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The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is:
- A. Pain.
- B. Impaired gas exchange.
- C. Decrease Cardiac output.
- D. Fluid volume excess.
Correct Answer: B
Rationale: Impaired gas exchange is the main issue in pulmonary edema.
A patient with end-stage liver failure tells the nurse, “If I can just live to see my first grandchild who is expected in 5 months, then I can die happy.” The nurse recognizes that the patient is demonstrating which of the following stages of grieving?
- A. Prolonged grief disorder
- B. Kübler-Ross’s stage of bargaining
- C. Kübler-Ross’s stage of depression
- D. The new normal stage of the Grief Wheel.
Correct Answer: B
Rationale: The patient is expressing a desire to delay death in exchange for a significant event, characteristic of the bargaining stage in Kübler-Ross's model of grief.
Prior to a thoracentesis, what intervention should the nurse complete?
- A. Measure oxygen saturation before and after the procedure.
- B. Verify that the client has given informed consent.
- C. Explain the procedure briefly to the client and their family.
- D. Ensure informed consent has been obtained from the client.
Correct Answer: D
Rationale: The correct answer is D because ensuring informed consent is crucial before any invasive procedure to protect the client's autonomy and rights. This involves confirming the client's understanding of the procedure, risks, benefits, and alternatives. Option B is correct as it directly relates to the ethical and legal aspect of the procedure. Option A is incorrect as it focuses solely on monitoring oxygen saturation, which is important but not the priority before thoracentesis. Option C is incorrect as simply explaining the procedure does not ensure the client's understanding or consent.
What is the rationale for using preoperative checklists on the day of surgery?
- A. The patient is correctly identified.
- B. All preoperative orders and procedures have been carried out and records are complete.
- C. Patients' families have been informed as to where they can accompany and wait for patients.
- D. Preoperative medications are the last procedure before the patient is transported to the operating room.
Correct Answer: B
Rationale: Checklists ensure all necessary steps are completed, enhancing patient safety.
What priority nursing action should you take?
- A. Notify the physician immediately
- B. Administer supplemental oxygen
- C. Have the student breathe into a paper bag
- D. Obtain an order for an anxiolytic medication
Correct Answer: C
Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.