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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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When a nurse is performing a neurological assessment, which of the following is most important to assess first?
- A. Patient's reflexes
- B. Patient's cranial nerve function
- C. Patient's level of consciousness
- D. Patient's pupil response
Correct Answer: C
Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.
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.
What question would you initially ask a patient who has a positive tuberculin test?
- A. Have you recently been hospitalized?
- B. Are you a member of the homeless population?
- C. Have you received bacille Calmette-Guérin (BCG)?
- D. Have you been out of the country over the past 3 months?
Correct Answer: C
Rationale: The correct initial question to ask a patient with a positive tuberculin test is whether they have received bacille Calmette-Guérin (BCG) vaccine. This is because BCG vaccination can cause a false positive result on the tuberculin test due to cross-reactivity with the purified protein derivative (PPD) used in the test. Asking about recent hospitalization (A), homelessness (B), or recent travel out of the country (D) would not provide relevant information regarding the interpretation of the positive tuberculin test.
A First Nations family requires dental care. The nurse needs to determine which of the following in order to facilitate the best possible care for this family?
- A. Do they have coverage under the Indian Act of 1876?
- B. Do they live on a reservation or in town?
- C. Do they have noninsured health benefits?
- D. Do they have their provincial health cards?
Correct Answer: C
Rationale: The correct answer is C: Do they have noninsured health benefits? This is because noninsured health benefits provide coverage for essential health services not covered by other plans for First Nations and Inuit people in Canada. It ensures access to necessary dental care for the family.
Incorrect choices:
A: Coverage under the Indian Act of 1876 is not directly related to accessing dental care; it pertains to legal and historical rights.
B: Living on a reservation or in town may not necessarily impact access to dental care, as healthcare services can vary.
D: Having provincial health cards is important for general healthcare, but specific benefits for First Nations may not be covered.
A nurse is assessing a 45-year-old male patient with a history of smoking. The nurse would be most concerned if the patient reports:
- A. Shortness of breath with minimal exertion.
- B. Occasional cough with mucus production.
- C. Slight wheezing after physical activity.
- D. Experiencing no symptoms related to smoking.
Correct Answer: A
Rationale: The correct answer is A because shortness of breath with minimal exertion indicates possible respiratory distress, which can be a sign of significant lung damage from smoking. This symptom suggests a decreased ability to exchange oxygen and carbon dioxide efficiently, potentially leading to serious health complications.
Choice B is incorrect because an occasional cough with mucus production is common in smokers and may not be as alarming as shortness of breath.
Choice C is incorrect as slight wheezing after physical activity could be due to exercise-induced asthma rather than solely smoking-related issues.
Choice D is incorrect because even though the patient may not be experiencing symptoms related to smoking currently, it does not rule out potential underlying lung damage or future health risks associated with smoking.