Correct Answer: D

Rationale: A respiratory rate of 28 breaths per minute (
D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (
A), fever (
B), and productive cough (
C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

Correct Answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (
A). It is essential to keep the joint uncovered (
B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy.

Choices (
C) and (
D) do not provide optimal support to the joint for effective movement.

Correct Answer: C

Rationale: It is essential for clients using herbal therapies to obtain herbs from manufacturers with a history of quality control for their supplements. This recommendation is crucial because quality control processes help in maintaining the purity and effectiveness of the herbal supplements. Option A is incorrect as it provides a negative and inaccurate generalization about herbs. Option B is also incorrect as there is existing evidence on the safety and efficacy of certain herbal supplements. Option D is not the most relevant information to offer initially to a client seeking advice on the general use of herbal supplements.

Correct Answer: B

Rationale: Hinge joints, like the elbow, primarily allow movement in one direction, in this case, bending the arm. The correct action to exercise hinge joints is to bend the arm by flexing the ulnar to the humerus. This movement specifically targets the hinge joint and promotes its range of motion.

Choices A, C, and D involve movements that do not specifically target hinge joints. Tilt the pelvis involves the ball-and-socket joints of the hip, turning the head involves the pivot joint of the neck, and extending the arm and rotating it in circles involve multiple joints including ball-and-socket and pivot joints.

Correct Answer: B

Rationale: The statement 'I should avoid using my inhaler unless I am having an asthma attack' (
B) indicates a need for further teaching. It is important for clients to use their inhaler as prescribed, which may include regular use to prevent asthma attacks.
Choice A is correct because using the inhaler when feeling short of breath can help manage asthma symptoms.
Choice C is also correct as using the inhaler before exercise can prevent exercise-induced symptoms.
Choice D is correct as rinsing the mouth after using the inhaler helps prevent oral thrush, a potential side effect of inhaled corticosteroids.
Therefore, option B is the most concerning statement that needs clarification.