Nokea
The nurse did an admission procedure. The best position to be assumed by Roy is _____.
- A. left lateral position with the affected side inferior.
- B. semi-fowler position at least 30 degrees.
- C. dorsal position with pillows under the chest.
- D. lying on his side, the affected side of the lungs should be superior.
Correct Answer: B
Rationale: The best position for a patient to assume during an admission procedure, particularly for respiratory assessment, is the semi-fowler position at least 30 degrees. In the semi-fowler position, the patient's head and upper body are elevated to a 30-degree angle. This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and enhancing chest expansion. It also facilitates breathing and allows for better assessment of respiratory status. Additionally, the semi-fowler position helps prevent aspiration and promotes comfort and relaxation for the patient during the admission procedure.
You may also like to solve these questions
The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?
- A. 4
- B. 2
- C. 1
- D. 3
Correct Answer: B
Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.
A 70- year-old has been rushed to the hospital due to bradycardia and palpitation. The physician suggested that a pacemaker be inserted to correct the symptoms. The patient voluntarily decides not to have the pacemaker Inserted. This is respected by the family. This is an example of what ethical principles
- A. Beneficence
- B. Autonomy
- C. Fidelity
- D. Justice
Correct Answer: B
Rationale: Autonomy is the ethical principle that respects an individual's right to make their own decisions about their medical treatment, even if it goes against medical advice or the preferences of others. In this case, the 70-year-old patient has voluntarily decided not to have the pacemaker inserted despite the physician's recommendation. The fact that the patient's decision is respected by the family reflects the importance of honoring the patient's autonomy and right to make decisions about their own healthcare.
What is the PRIORITY of care for patient diagnosed with Guillain-Barre Syndrome?
- A. Maintenance of respiratory function
- B. Prevention of decubitus
- C. Control of urinary tract infection
- D. Replacement of fluid and electrolytes
Correct Answer: A
Rationale: The priority of care for a patient diagnosed with Guillain-Barre Syndrome is the maintenance of respiratory function. Guillain-Barre Syndrome can cause paralysis, including respiratory muscles, leading to respiratory failure. Ensuring adequate ventilation and oxygenation is crucial to prevent complications such as respiratory failure and the need for mechanical ventilation. Monitoring for signs of respiratory distress, such as shortness of breath, decreased oxygen saturation, and diminished lung sounds, is essential in providing prompt intervention and support for the patient's respiratory needs. Other aspects of care, such as prevention of decubitus ulcers, control of urinary tract infections, and replacement of fluid and electrolytes, are also important but not as immediate or life-threatening as ensuring adequate respiratory function in these patients.
Which of the following clinical findings is most consistent with a diagnosis of pneumonia?
- A. Inspiratory crackles and dullness to percussion
- B. Hemoptysis and pleuritic chest pain
- C. Clubbing of the fingers and cyanosis
- D. Decreased breath sounds and tracheal deviation
Correct Answer: A
Rationale: The clinical findings of inspiratory crackles (also known as rales) and dullness to percussion are most consistent with a diagnosis of pneumonia. Inspiratory crackles are abnormal lung sounds heard on auscultation and are typically due to the presence of fluid or mucus in the alveoli. Dullness to percussion can indicate consolidation of lung tissue, which is a common finding in pneumonia where the alveolar spaces are filled with inflammatory exudate. These findings suggest localized lung pathology and are commonly observed in patients with pneumonia. Hemoptysis and pleuritic chest pain (Choice B) are more suggestive of pulmonary embolism or pleurisy. Clubbing of the fingers and cyanosis (Choice C) are signs of chronic hypoxemia and are not specific to pneumonia. Decreased breath sounds and tracheal deviation (Choice D) are more indicative of conditions such as a pneumoth
After the surgical procedure, the nurse assists with applying the surgical dressing. What is the nurse's priority action?
- A. Documenting the dressing change in the patient's chart
- B. Assessing the surgical incision for signs of complications
- C. Providing instructions to the patient about wound care
- D. Ensuring that the dressing is applied securely and correctly
Correct Answer: B
Rationale: The nurse's priority action after applying the surgical dressing is to assess the surgical incision for signs of complications. This includes checking for any signs of infection, excessive bleeding, or other complications related to the surgical site. Early detection of such complications is crucial for ensuring proper healing and preventing serious complications. Once the assessment is done and any issues are addressed, the nurse can proceed with documenting the dressing change, providing instructions to the patient about wound care, and ensuring that the dressing is securely and correctly applied.