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While auscultating for heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
- A. Document the findings on the patient's record.
- B. Wait 10 minutes, and auscultate the heart again.
- C. Ask another nurse to double-check the finding.
- D. Ask the patient to take deep breaths and check for changes in their physical condition.
Correct Answer: A
Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.
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A nurse is caring for a patient with hypertension. The nurse should educate the patient to avoid which of the following?
- A. Limiting caffeine intake.
- B. Consuming more fruits and vegetables.
- C. Increasing salt intake.
- D. Increasing physical activity.
Correct Answer: C
Rationale: The correct answer is C: Increasing salt intake. Salt intake can worsen hypertension by causing water retention and increasing blood pressure. Limiting caffeine intake (A) and increasing physical activity (D) are beneficial for managing hypertension. Consuming more fruits and vegetables (B) is also recommended as they are part of a healthy diet that can help lower blood pressure. Overall, educating the patient to avoid increasing salt intake is crucial in managing hypertension effectively.
A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.
Which technique should be used to assess a murmur in a patient's heart?
- A. The bell of the stethoscope
- B. The diaphragm of the stethoscope
- C. Palpation with the palm of the hand
- D. Ask another nurse to double-check the finding.
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location.
A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs.
C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs.
D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.
Which of the following statements illustrates the biomedical model of Western traditional views?
- A. Health is viewed as the absence of disease.
- B. Optimal health is viewed as high-level wellness.
- C. Health and disease are considered parts of a cyclical process.
- D. The treatment of disease is nursing's primary focus.
Correct Answer: A
Rationale: The correct answer is A because the biomedical model focuses on defining health as the absence of disease. This model emphasizes biological factors in understanding and treating illnesses. It is reductionist in nature, viewing health issues as purely physical and separate from social or psychological aspects. Choices B, C, and D do not align with the biomedical model. B emphasizes overall well-being, not just the absence of disease. C suggests a more holistic approach, while D implies a focus on nursing rather than the medical model's emphasis on disease treatment.
A nurse is assessing a patient with chronic kidney disease. The nurse should prioritize which of the following lab values?
- A. Serum creatinine levels.
- B. Hemoglobin levels.
- C. White blood cell count.
- D. Platelet count.
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine levels. In patients with chronic kidney disease, monitoring serum creatinine levels is crucial because it reflects kidney function. An increase in creatinine levels indicates worsening kidney function. Hemoglobin levels (B) are important in assessing anemia, common in CKD, but not the priority. White blood cell count (C) and platelet count (D) may indicate infection or bleeding, respectively, but are not specific to kidney function in this context.