Nokea
When auscultating Mr. Puff’s chest, what would you expect to find?
- A. Absent breath sounds
- B. Bronchial breath sounds with rales
- C. Decreased vesicular breath sounds with prolonged expiration
- D. Normal breath sounds with prolonged inspiration
Correct Answer: C
Rationale: Air trapping causes prolonged expiration in COPD.
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What factor would be most important to include in Wendy’s discharge teaching plan?
- A. Effective breathing and coughing techniques
- B. Scheduling of return follow-up visits
- C. Program of recommended and contraindicated activities
- D. Individualized measures to prevent future attacks
Correct Answer: D
Rationale: Preventive measures reduce the likelihood of recurrent attacks.
Paralytic ileus may occur as a postoperative complication. Which of the following patients would cause you the greatest concern about the development of paralytic ileus?
- A. Kim, a 27-year-old postlaparoscopic appendectomy.
- B. Joyce, a 39-year-old post–open right hemicolectomy.
- C. Nancy, a 56-year-old postmediastinoscopy.
- D. John, a 47-year-old post–total joint replacement.
Correct Answer: B
Rationale: Open abdominal surgeries increase the risk of paralytic ileus.
In doing a nutritional assessment for Mrs. Collins who wants to lose weight, what should the nurse initially do?
- A. Ask her to describe her actual food intake and behaviors influencing eating
- B. Determine who does the cooking and shopping
- C. Determine what she knows about the basic four food groups
- D. Determine biochemical data such as urinalysis and blood chemistries
Correct Answer: A
Rationale: Understanding the patient's current eating habits and behaviors is crucial for tailoring an effective weight loss plan.
A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?
- A. The client is experiencing an aura.
- B. The client's antiseizure medication level is within the therapeutic range.
- C. The client has been seizure-free for 2 years.
- D. The client's seizure activity lasts longer than 5 minutes.
Correct Answer: D
Rationale: The correct answer is D because prolonged seizures lasting longer than 5 minutes can lead to status epilepticus, a medical emergency that can cause brain damage or even death. Immediate intervention is necessary to stop the seizure activity. Auras (A) are warning signs of an impending seizure and do not require immediate intervention. Antiseizure medication within therapeutic range (B) indicates proper management. Being seizure-free for 2 years (C) is a positive outcome but does not require immediate intervention unless a seizure occurs.
In developing a discharge plan for a patient requiring home-care services, what is important to assess?
- A. Patient’s nursing diagnosis
- B. Availability of needed community services
- C. Patient’s functional abilities
- D. Patient’s family dynamics
Correct Answer: B
Rationale: Ensuring access to necessary community services is vital for successful home care.