A nurse is documenting the results of assessment of a patient with bronchiectasis. What would the nurse most likely include in documentation?

Correct Answer: D

Rationale: In bronchiectasis, clubbing of the fingers is a likely finding for documentation, resulting from chronic hypoxia as dilated bronchi impair gas exchange. This physical sign widened, rounded fingertips reflects prolonged respiratory insufficiency from copious sputum and recurrent infections, common in this condition. Sudden pleuritic chest pain suggests pulmonary embolism or pleurisy, not bronchiectasis's chronic course. Wheezes indicate bronchospasm, typical in asthma, not the wet cough of bronchiectasis. Increased A-P diameter (barrel chest) occurs in COPD's emphysema, not bronchiectasis's bronchial dilation. The nurse's note on clubbing observed via inspection captures a key clinical feature, aiding diagnosis tracking and care planning (e.g., oxygen needs) for this irreversible airway disease.

Correct Answer: B

Rationale: Moderate sedation, or conscious sedation, is used for procedures like colonoscopies, inducing a depressed level of consciousness where patients remain responsive but relaxed, reducing anxiety and discomfort without full anesthesia. It's not tied to outpatient status many outpatient procedures use local or no sedation. Loss of sensation requires regional anesthesia, like a nerve block, not moderate sedation, which preserves sensation. Immobility is achieved with general anesthesia, not this lighter state where patients can still move. This sedation level allows quick recovery, ideal for ambulatory settings, while maintaining airway control. The nurse's understanding ensures proper monitoring for oversedation risks, aligning with safe administration to achieve the intended conscious yet calm state during the procedure.

Correct Answer: A

Rationale: Performing hand hygiene first prevents microbial transmission, a foundational step before any patient contact or device use like the incentive spirometer. This reduces infection risk, critical post-surgery when immunity may be compromised. Positioning in reverse Trendelenburg or high Fowler's follows, aiding lung expansion, but hygiene precedes to ensure safety. Explaining the mouthpiece and instructing slow inhalation are teaching steps, done after hands are clean to avoid contamination. The nurse's adherence to this sequence hygiene first upholds asepsis, setting the stage for effective spirometry to prevent atelectasis, aligning with infection control and respiratory care standards.

Correct Answer: A

Rationale: Being free of burns at the grounding pad is the most appropriate intraoperative outcome, as cautery use risks electrical burns if pads are misplaced a preventable injury under the nurse's watch. Infection signs emerge post-surgery, not intraoperatively. Nausea and pain are irrelevant during anesthesia patients are unconscious, with symptoms surfacing later. The circulating nurse's focus on equipment safety, like pad placement, ensures skin integrity, aligning with intraoperative advocacy to prevent immediate harm, per surgical care standards.

Correct Answer: A

Rationale: Socialization is the process by which individuals acquire the knowledge, skills, and attitudes needed to participate in society. Its functions include moral development (learning ethical standards), personality development (forming individual traits), and the development of defense mechanisms (coping strategies for social pressures). The question asks for an option that is not a function but rather the process itself. 'Socialization,' is the process, not an outcome, making it the exception and the correct answer. 'Moral development,' is a function, as socialization instills moral norms, per Lawrence Kohlberg's stages of moral growth. 'Personality development,' is another function, aligning with Sigmund Freud's view that social interactions shape personality. 'Development of defense mechanism,' is a function too, as individuals learn adaptive responses through social experiences, per psychoanalytic theory. Socialization as a term describes the mechanism, not a specific result, distinguishing it from the functional outcomes in B, C, and D, thus confirming A as the correct choice.