A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended?

Correct Answer: C

Rationale: Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).

Correct Answer: D

Rationale: The correct answer is D) Stomach. Protein and fat digestion begin in the stomach. Protein digestion starts in the stomach due to the presence of pepsin, an enzyme that breaks down proteins into smaller peptides. Fat digestion also begins in the stomach with the action of gastric lipase, although its contribution to fat digestion is minimal compared to other enzymes in the small intestine. The other options are incorrect: A) Mouth: While some digestion of carbohydrates begins in the mouth with the action of salivary amylase, protein and fat digestion do not start here. B) Esophagus: The esophagus is a muscular tube that serves to transport food from the mouth to the stomach and does not play a role in digestion. C) Small intestine: While the majority of protein and fat digestion occurs in the small intestine with the help of enzymes like pancreatic lipase and proteases, the initial breakdown of these nutrients starts in the stomach. Understanding the process of digestion is crucial in nursing, especially when caring for patients with gastrointestinal issues or those who require nutritional support. Knowing where digestion begins helps nurses provide appropriate dietary recommendations and interventions to optimize nutrient absorption and support overall patient health. By understanding the specific roles of different organs in the digestive system, nurses can better assess, plan, and implement care plans to meet the nutritional needs of their patients.

Correct Answer: D

Rationale: Educational Rationale: The correct answer is D) Vitamin D. Vitamin D deficiency is linked to rickets due to its crucial role in regulating calcium and phosphorus levels in the body. Vitamin D helps in the absorption of calcium from the intestines, which is essential for bone mineralization and strength. Inadequate levels of Vitamin D can lead to impaired calcium absorption, resulting in weak, soft bones seen in rickets. Option A) Vitamin A is not associated with rickets. Vitamin A plays a role in vision, immune function, and skin health, but it is not directly involved in bone metabolism. Option B) Vitamin B is a group of multiple water-soluble vitamins that are essential for various bodily functions but are not specifically linked to rickets or bone health. Option C) Vitamin C is important for collagen synthesis, immune function, and wound healing, but it is not the primary vitamin implicated in rickets. Educational Context: Understanding the relationship between Vitamin D deficiency and rickets is crucial for nursing students as they care for patients at risk for nutritional deficiencies. Nurses need to recognize the signs and symptoms of rickets, such as bone deformities and fractures, and understand the importance of proper nutrition in preventing this condition. By knowing the role of different vitamins in the body, nurses can promote optimal health and provide evidence-based care to patients with various health conditions. By mastering the fundamentals of nutrition, nurses can educate patients on maintaining a balanced diet rich in essential vitamins and minerals. This knowledge empowers nurses to advocate for proper nutrition interventions to prevent conditions like rickets and promote overall health and well-being in their patients.

Correct Answer: B

Rationale: The correct answer, B) Pour 30 ml of water before and after feeding administration, is the most appropriate option for colostomy feeding. Flushing the tube with water before and after feeding helps maintain tube patency by preventing clogging and ensures proper hydration of the patient. This practice also helps in preventing infection and maintaining the integrity of the stoma. Option A is incorrect because holding the syringe 18 inches above the stoma and administering the feeding slowly can cause discomfort and increase the risk of aspiration. Option C is incorrect because inserting the ostomy feeding tube only 1 inch towards the stoma may not provide proper placement for effective feeding. Option D is incorrect because the color of the stoma (pink in this case) does not solely indicate the adequacy of circulation. Circulation assessment should involve checking for signs of perfusion such as capillary refill, temperature, and color changes in the stoma area. In an educational context, understanding the correct procedure for colostomy feeding is crucial for nursing students to provide safe and effective care to patients with ostomies. Proper technique not only ensures patient comfort but also prevents complications such as infection, blockages, or injury to the stoma site. Students should be taught the rationale behind each step to promote critical thinking and evidence-based practice in nursing care.

Correct Answer: C

Rationale: In this respiratory assessment scenario of a client with pleural effusion, the correct finding the nurse would anticipate is a decrease in chest movement on the affected side (Option C). Pleural effusion, which is the accumulation of fluid in the pleural space surrounding the lungs, restricts lung expansion, leading to reduced chest movement on the affected side. Option A, fever, is not a typical finding in pleural effusion unless there is an underlying infection present. Option B, normal bronchial sounds, would not be expected as pleural effusion is more likely to cause decreased or absent breath sounds. Option D, hyper-resonance percussion, is not characteristic of pleural effusion but may be seen in conditions like emphysema. Educational context: Understanding respiratory assessments and associated findings is crucial for nurses to accurately assess and manage clients with respiratory conditions. By recognizing the specific signs and symptoms of pleural effusion, nurses can provide timely interventions and improve patient outcomes. This knowledge also helps in differentiating between various respiratory conditions, guiding appropriate care and treatment plans for patients.