Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:

Correct Answer: C

Rationale: Tachypnea refers to an abnormally rapid breathing rate, specifically defined as a respiratory rate exceeding 20 breaths per minute in adults at rest. In this scenario, Jake's respiratory rate is 30 breaths per minute, which clearly fits the definition of tachypnea. This condition often signals an underlying issue such as respiratory distress, infection, or anxiety, requiring further investigation by the healthcare team. The nurse's recognition and documentation of tachypnea are critical for ensuring timely intervention. The other options are unrelated: a pulse rate over 100 beats per minute defines tachycardia, not tachypnea; blood pressure of 140/90 indicates hypertension, which is a cardiovascular parameter; and frequent bowel sounds pertain to gastrointestinal activity, not respiration. Thus, the correct understanding of tachypnea aligns with a respiratory rate greater than 20 breaths per minute, making it the most accurate choice in this context.

Correct Answer: D

Rationale: The scientific method hypothesizing, experimenting, analyzing, concluding grounds research, offering a systematic, objective way to build knowledge. In nursing, it validates practices (e.g., hand hygiene efficacy), ensuring evidence is reliable. Evidence is research's product, not its foundation; it emerges from the method. Experience informs hypotheses but is subjective, lacking rigor without structure e.g., a nurse's hunch needs testing. Self-actualization, a Maslow need, relates to personal growth, not research's basis; it's irrelevant here. The scientific method's disciplined approach distinguishes research from intuition, enabling nurses to trust findings for practice (e.g., wound care protocols), making it the cornerstone of credible, reproducible research in healthcare.

Correct Answer: A

Rationale: A newborn's normal heart rate ranges from 120-160 beats per minute at rest, per pediatric norms. At 152 bpm and regular, this falls within healthy limits, reflecting a typical neonatal cardiovascular response e.g., higher rates due to immature regulation. Notifying the physician is unnecessary without distress signs (e.g., cyanosis), as this isn't abnormal. Monitoring is routine but not the priority action documentation suffices unless trends shift. Assessing for circulatory distress (e.g., poor perfusion) is proactive, but with regularity and no symptoms, it's not indicated. Documenting as normal aligns with evidence-based practice, ensuring accurate records without escalating a non-issue, standard for stable newborns.

Correct Answer: C

Rationale: Immunity is the body's defense mechanism against pathogens.

Correct Answer: A

Rationale: A cleansing bed bath aims to clean, refresh, and comfort bedridden clients.