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The student observes a patient with no breathing problems. Which action by the student indicates a need to review respiratory assessment skills?
- A. The student starts at the apices of the lungs and moves to the bases.
- B. The student compares breath sounds from side to side, avoiding bony areas.
- C. The student places the stethoscope over the posterior chest and listens during expiration.
- D. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
Correct Answer: C
Rationale: The correct answer is C. Listening only during inspiration instead of both inspiration and expiration indicates a need for a review of respiratory assessment skills. During chest auscultation, it is essential to listen to at least one cycle of inspiration and expiration at each placement of the stethoscope. Instructing the patient to breathe slowly and a little deeper than normal through the mouth is a correct practice during auscultation. The correct sequence for lung auscultation is from the apices to the bases, comparing breath sounds bilaterally, avoiding bony areas. It is crucial to place the stethoscope over lung tissue rather than bony prominences to accurately assess lung sounds.
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Patients exhibiting signs of cyanosis will:
- A. show signs of hyperoxia.
- B. have increased O2 saturation.
- C. have blood levels of CO2 higher than O2 levels.
- D. None of the above.
Correct Answer: C
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.
A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?
- A. Send a text to the client to confirm the location of the house
- B. Leave her purse and valuables on the seat in the car and lock the doors
- C. Ask the client to keep an extra set of keys in case the car is locked
- D. Keep the car windows rolled up when in an unfamiliar environment
Correct Answer: D
Rationale: The correct answer is to keep the car windows rolled up when in an unfamiliar environment. This action helps uphold safety precautions for the home health nurse. When visiting a new client in an unfamiliar area, it is essential to ensure personal safety. Keeping the car windows rolled up can prevent potential intruders or unwanted individuals from gaining access to the nurse while in the vehicle. This precaution is important for personal safety and security.
Choice A, sending a text to the client to confirm the location of the house, is not directly related to the nurse's safety during the visit. While communication with the client is important, it does not directly address the nurse's safety.
Choice B, leaving her purse and valuables on the seat in the car, poses a security risk. It is not advisable to leave valuables visible in the car, as it may attract thieves and compromise the nurse's safety.
Choice C, asking the client to keep an extra set of keys, is more related to accessibility and convenience rather than the nurse's safety. While having an extra set of keys may be helpful, it does not directly address safety precautions for the nurse.
Which principle of body mechanics may help to reduce the risk of a back injury?
- A. Maintain a wide base of support
- B. Bend from the knees, not the waist
- C. Keep the back straight while lifting
- D. Push or pull objects rather than lifting
Correct Answer: C
Rationale: Proper body mechanics are crucial to prevent injuries, especially for professions involving lifting and moving objects. Keeping the back straight while lifting is essential to reduce the risk of back injuries as it helps maintain the spine's natural alignment and prevents excessive strain on the back muscles. Choosing choices A, B, and D would increase the risk of back injury. Maintaining a wide base of support provides stability, bending from the knees instead of the waist protects the lower back, and pushing or pulling objects reduces the strain on the back muscles, all contributing to preventing back injuries.
Should standard precautions be used when providing post mortem care to a patient who has died from a massive heart attack and had no other diseases, illnesses, or infections?
- A. Yes, because the patient must be treated with respect
- B. Yes, you still must use standard precautions
- C. No, because the patient had no infections
- D. No, because this is not respectful
Correct Answer: B
Rationale: Yes, you must still use standard precautions when providing post mortem care, regardless of the patient's medical history. Standard precautions are essential to prevent the transmission of potential infectious agents and protect both the healthcare provider and others from exposure. Even if the patient did not have known infections, it is crucial to maintain a safe environment and uphold professional standards of care. Choice A is incorrect as using standard precautions is primarily for infection control rather than solely for respect. Choices C and D are incorrect as the absence of infections or the notion of respect does not negate the need for standard precautions in post mortem care.
What does the medical term 'diaphoresis' mean?
- A. Profuse vomiting
- B. Profuse sweating
- C. Gasping for air
- D. None of the above
Correct Answer: B
Rationale: The correct answer is B: Profuse sweating. Diaphoresis is a medical term that refers to excessive sweating. It is commonly seen in emergency situations such as heart attacks or diabetic episodes. Choice A, 'Profuse vomiting,' is incorrect as diaphoresis is not related to vomiting. Choice C, 'Gasping for air,' is also incorrect as it refers to difficulty breathing, not sweating. Choice D, 'None of the above,' is incorrect as diaphoresis specifically relates to sweating.