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nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork belowi. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
- D. D
Correct Answer:
Rationale: Correct Answer: B
Rationale: Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation. Auscultating at location B (lower anterior chest wall) allows for better detection of crackles in the bases of the lungs where pneumonia commonly affects. This area corresponds to the lower lobes where consolidation occurs, leading to crackles. Auscultating at other locations (A, C, D) may not yield clear crackle sounds associated with pneumonia.
Summary of other choices:
A (Location A - upper anterior chest wall): Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation.
C (Location C - middle anterior chest wall): Crackles in pneumonia are not typically heard in the middle lung fields.
D (Location D - upper lateral chest wall): Crackles in pneumonia are not typically heard in the upper lateral chest wall.
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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr.
- B. A client who received a pain medication 30 min ago for postoperative pain.
- C. A client who was just given a glass of orange juice for a low blood glucose level.
- D. A client who has 100 mL of fluid remaining in his IV bag.
Correct Answer: C
Rationale: The nurse should assess client C first because low blood glucose levels can lead to serious complications if not addressed promptly. Hypoglycemia can result in altered mental status, seizures, and even coma. Assessing and addressing this client's low blood glucose level is a priority to prevent further deterioration.
Clients A, B, and D do not have immediate life-threatening conditions that require urgent assessment compared to client C. Client A, scheduled for a procedure in 1 hr, can be assessed after client C. Client B, who received pain medication 30 min ago, would have some time before needing reassessment. Client D, with 100 mL of fluid remaining in the IV bag, can also wait as long as there is no indication of the client being dehydrated or in need of immediate intervention.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences.
- C. Speak directly to the client.
- D. Use gestures to convey meaning.
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is crucial as it maintains a connection with the client, shows respect, and ensures understanding. Speaking to the interpreter directly can lead to misinterpretation. Speaking slowly (A) may come across as patronizing. Pausing in the middle of sentences (B) can disrupt communication flow. Using gestures (D) may help but should not replace direct verbal communication. The other choices are not as effective in ensuring clear communication and building trust with the client.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares, face, and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the correct action because excessive oxygen flow can lead to oxygen toxicity and respiratory depression in patients. Nasal cannulas are commonly used for oxygen therapy and a flow rate of more than 6 L/min can cause discomfort and dryness of the nasal passages. It is important to adhere to evidence-based practice guidelines to ensure patient safety and well-being.
Choice A is incorrect because aligning the flow rate with the top of the ball inside the flow meter is not a reliable method for regulating oxygen flow. Choice C is incorrect as the reservoir bag of a partial rebreathing mask should remain inflated to ensure an adequate oxygen supply. Choice D is incorrect as petroleum jelly should not be used in oxygen therapy due to the risk of flammability.
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. If there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A is the correct choice because it acknowledges the client's interest in alternative therapies and offers to review information to help select a safe practitioner. This response shows support for the client's autonomy and involves them in the decision-making process. It also ensures the client's safety by emphasizing the importance of selecting a reputable practitioner.
Incorrect Choices:
B: This choice assumes the provider will automatically inform the client about therapies, which may not always be the case. It does not actively involve the client in their care.
C: While it supports the client's autonomy, it lacks guidance on selecting a safe practitioner and may not prioritize the client's safety.
D: Suggesting online support groups for remedies may not ensure the safety or efficacy of the therapies, and it does not involve professional guidance.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
- A. Limit alcohol intake to 0 oz per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an anti-obesity medication.
- D. Administer an antihypertensive medication.
- E. Limit foods high in potassium.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.