In developing a discharge plan for a patient requiring home-care services, what is important to assess?

Correct Answer: B

Rationale: Ensuring access to necessary community services is vital for successful home care.

Correct Answer: B

Rationale: A tuberculin skin test detects latent TB infection, even without symptoms.

Correct Answer: C

Rationale: The correct answer is C because the pain of a myocardial infarction (MI) typically lasts longer than 15 minutes, unlike stable angina which lasts for a shorter duration. MI pain is usually described as intense, crushing, and prolonged, whereas stable angina pain is often triggered by exertion and relieved by rest or medication like nitroglycerin. Choices A, B, and D are incorrect because shortness of breath, feelings of fear or anxiety, and lack of relief from nitroglycerin are not definitive differentiating factors between MI and stable angina.

Correct Answer: B

Rationale: Thrombolytics can dissolve clots if administered within the therapeutic window.

Correct Answer: D

Rationale: The correct answer is D, assessing the client's mental status and level of consciousness. This is the first action to take because a respiratory rate of 10 breaths/min in a COPD client receiving oxygen therapy may indicate respiratory depression or impending respiratory failure. Assessing mental status and level of consciousness can help determine if the client is experiencing hypoxia. Increasing oxygen flow rate (A) without assessing the client first can be dangerous if the client is retaining carbon dioxide. Administering a bronchodilator (B) may not address the underlying issue of respiratory depression. Encouraging deep breaths (C) may not be appropriate if the client is in respiratory distress.

Correct Answer: B

Rationale: The correct answer is B: Administer pain medication as needed. In acute pancreatitis, pain management is crucial to provide comfort and improve outcomes. Pain medication helps alleviate the severe abdominal pain associated with pancreatitis. It is essential to treat pain promptly to prevent complications and improve the client's quality of life. Encouraging a high-protein diet (A) is not recommended as it may exacerbate pancreatitis symptoms. Providing small, frequent meals (C) may help reduce the workload on the pancreas, but pain management takes precedence. Increasing oral fluid intake (D) is important for hydration but does not address the primary concern of pain relief in acute pancreatitis.

Correct Answer: C

Rationale: The correct answer is C because reduced breath sounds after an open lung biopsy could indicate a potential complication like pneumothorax. In this situation, it is crucial for the nurse to call the physician immediately for further assessment and intervention. This prompt action can help prevent worsening of the client's condition and ensure timely treatment. Choice A is incorrect because applying oxygen and pulse oximetry is not directly addressing the potential complication of reduced breath sounds. Choice B is incorrect because withholding pain medication based solely on a low heart rate is not appropriate without further assessment. Choice D is incorrect because decreasing oxygen flow rate without proper assessment could be harmful if the client is experiencing respiratory distress.

Correct Answer: B

Rationale: The correct answer is B: Serum potassium. In acute renal failure, impaired kidney function can lead to electrolyte imbalances, especially hyperkalemia which can be life-threatening. Monitoring serum potassium levels is crucial to prevent cardiac complications. Serum sodium (A) may be altered, but potassium is more critical. Serum calcium (C) and chloride (D) levels are important but not as directly impacted in acute renal failure compared to potassium.

Correct Answer: C

Rationale: Hoarseness or voice changes are early signs of laryngeal cancer.