A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?

Correct Answer: B

Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.

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.

Correct Answer: C

Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.

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.

Correct Answer: B

Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location. A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs. C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs. D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.