The nurse is assessing a teenage girl newly admitted to the pediatric unit. What efficient framework provides additional modesty?

Correct Answer: D

Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy. A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach. B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health. C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.

Correct Answer: B

Rationale: The correct answer is B: Avoiding environmental allergens and smoking. Environmental allergens and smoking are common triggers for asthma attacks. Avoiding these triggers can significantly reduce the risk of exacerbations. Over-the-counter medications may provide symptomatic relief but do not address the underlying triggers. Increasing physical activity can be beneficial but may also trigger asthma attacks in some individuals. Limiting fluid intake to reduce mucus production is not a recommended strategy for managing asthma triggers.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.

Correct Answer: D

Rationale: Step 1: Culturally competent care involves applying knowledge, skills, attitudes, and personal attributes to provide respectful and effective care. Step 2: Understanding and speaking the patient's mother tongue (Option A) is important but not sufficient for culturally competent care. Step 3: Possessing basic knowledge of the patient's cultural background (Option B) is helpful, but not comprehensive enough to ensure culturally competent care. Step 4: Having knowledge of the significance of social, economic, and cultural contexts (Option C) is crucial but does not encompass the full scope of culturally competent care. Step 5: The correct answer, D, encompasses the holistic approach needed for culturally competent care by emphasizing the application of knowledge, skills, attitudes, and personal attributes to maximize respect and care.

Correct Answer: B

Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.

Correct Answer: A

Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.

Correct Answer: D

Rationale: The correct answer is D: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, pneumonia, and muscle weakness. It improves circulation, lung function, and overall recovery. Administering pain medication regularly (A) is important but not the top priority. Deep breathing exercises (B) are beneficial but not as crucial as early ambulation post-hip replacement. Monitoring for signs of infection (C) is essential but not the top priority for preventing complications in this case.

Correct Answer: C

Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.