A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following assessments?

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Question 1 of 9

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following assessments?

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Question 2 of 9

What type of assessment focuses on roles and relationships of the client?

Correct Answer: C

Rationale: The correct answer is C: Functional. Functional assessment focuses on roles and relationships of the client by evaluating how well they can perform daily activities and interact with others. This type of assessment provides valuable insights into a client's overall well-being and ability to function independently. Incorrect choices: A: Body systems - This type of assessment focuses on the physical structures and functions of the body, not on the client's roles and relationships. B: Head to toe - This refers to a comprehensive physical examination from head to toe, which does not specifically address the client's roles and relationships. D: Focused - This type of assessment targets a specific issue or concern, but it may not necessarily delve into the client's roles and relationships.

Question 3 of 9

Which of the following instructions should the nurse include when teaching parents about feeding their infant?

Correct Answer: A

Rationale: The correct answer is A because using the defrost setting on microwave ovens can help safely heat breast milk or formula for the infant without compromising its quality. This method ensures that the milk is heated evenly and prevents hot spots that could burn the baby's mouth. Choice B is incorrect because refrigerating partially used bottles can lead to bacterial growth and contamination. Choice C is incorrect as mixing water and concentrate in different ratios can result in either too diluted or too concentrated formula, which can be harmful to the infant. Choice D is incorrect as adding new formula to partially used bottles can also lead to bacterial growth and spoilage.

Question 4 of 9

The nurse is using a stethoscope to listen for bowel sounds. What should the nurse ensure before using the stethoscope?

Correct Answer: B

Rationale: The correct answer is B: Check the room temperature. This is important because extreme temperatures can affect the accuracy of bowel sound assessment. Cold temperatures can cause vasoconstriction, leading to decreased bowel sounds, while warm temperatures can lead to increased sounds due to increased blood flow. Choice A (Clean the stethoscope before use) is important for infection control but not directly related to ensuring accurate bowel sound assessment. Choice C (Place the stethoscope directly on the skin) is incorrect as bowel sounds are auscultated through clothing. Choice D (Use a hand sanitizer after use) is important for hand hygiene but not necessary before using the stethoscope for bowel sounds.

Question 5 of 9

Which medication should be expected for a client immobilized in traction and experiencing constipation?

Correct Answer: D

Rationale: The correct answer is D: Colace. When a client is immobilized and experiencing constipation, a stool softener like Colace is appropriate to prevent straining and discomfort. Advil and Anasaid are pain relievers, not laxatives. Clinocil is not a recognized medication. Colace is the best choice to address constipation in this scenario.

Question 6 of 9

When percussing over the ribs of a patient, the nurse notes a dull sounThe nurse would:

Correct Answer: A

Rationale: The correct answer is A because the dull sound over the ribs is a normal finding due to the presence of underlying solid structures such as the liver or spleen. Repositioning the hands or using more force is unnecessary as it won't change the nature of the sound. Referring the patient for additional investigation (choice D) is not warranted as this finding is commonly expected during percussion over the ribs.

Question 7 of 9

Recent Canadian immigration statistics indicate that the majority of people in this country settle in:

Correct Answer: C

Rationale: The correct answer is C: large-census metropolitan areas. This is supported by the fact that large cities like Toronto, Montreal, and Vancouver attract the most immigrants due to job opportunities, diverse communities, and cultural amenities. These cities offer better infrastructure and services compared to smaller areas, making them more appealing for settlement. Choices A and B are incorrect because smaller areas may lack the resources and opportunities that large cities provide. Choice D is incorrect as extremely large cities might be overwhelming and less conducive to successful integration for newcomers. Therefore, the majority of immigrants settling in Canada choose large-census metropolitan areas for better prospects and quality of life.

Question 8 of 9

Which of the following is the most important goal for a nurse when implementing care for a patient with a chronic illness?

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.

Question 9 of 9

A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that it is important to include cultural information in his health assessment to:

Correct Answer: D

Rationale: The correct answer is D: provide culturally sensitive and appropriate care. Including cultural information in the health assessment helps healthcare providers understand the patient's beliefs, practices, and preferences, allowing for tailored care that respects the patient's cultural background. This improves communication, trust, and overall health outcomes. Choice A is incorrect because cultural information does not necessarily identify the cause of an illness. Choice B is incorrect as it overemphasizes diagnosis without considering the patient's cultural context. Choice C is incorrect as it does not directly address the importance of cultural information in healthcare.

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