What is the term used for normal respiratory rhythm and depth in a client?

Correct Answer: A

Rationale: Eupnea describes normal breathing regular rhythm and adequate depth typically 12-20 breaths per minute in adults. Apnea is the absence of breathing, bradypnea is abnormally slow, and tachypnea is rapid. Recognizing eupnea during assessment confirms respiratory health, while deviations signal issues like hypoxia or obstruction. This baseline helps nurses monitor changes, ensuring timely interventions if breathing patterns shift, maintaining oxygenation critical for all body functions.

Correct Answer: B

Rationale: About 80% of bilirubin comes from hemoglobin breakdown in old red blood cells, processed by the spleen and liver. The rest (20%) is from other heme sources (e.g., myoglobin). Nurses monitor bilirubin in jaundice, understanding its RBC origin to assess liver function or hemolysis, critical for diagnosing underlying conditions.

Correct Answer: C

Rationale: Capillary refill greater than 3 seconds and buccal cyanosis signal severe oxygenation issues, critical in a pneumonia patient. Delayed refill indicates poor peripheral perfusion, while buccal cyanosis (blue-tinged oral mucosa) suggests central hypoxemia both life-threatening if untreated. Pneumonia impairs gas exchange, and these findings suggest worsening respiratory failure, demanding urgent intervention like oxygen therapy or escalation. Orientation to time, place, and date is reassuring, showing intact cognition, not immediate danger. Clear breath sounds are positive, indicating no consolidation or fluid, though not definitive in pneumonia's patchy presentation. Hemoglobin of 13 g/dl is normal, ensuring adequate oxygen-carrying capacity. The perfusion and oxygenation deficits outweigh other data, prioritizing immediate action to stabilize this vulnerable 68-year-old, aligning with nursing's focus on acute physiological threats.

Correct Answer: C

Rationale: Good communication and critical thinking are the most crucial skills for obtaining accurate client information. Communication listening, questioning, clarifying builds trust, encouraging honest responses (e.g., detailed pain history). Critical thinking analyzes these responses, spotting inconsistencies or probing deeper (e.g., linking fatigue to sleep issues), ensuring data reliability. Teaching and assessment are roles, not skills for gathering data; teaching informs, doesn't collect. Cognitive skills overlap with critical thinking, but pairing with teaching misses communication's primacy. Psychomotor skills (e.g., taking vitals) and courage are useful but secondary manual tasks don't extract perceptions, and bravery doesn't ensure accuracy. Communication and critical thinking together elicit and interpret client input effectively, foundational for a precise, comprehensive assessment in nursing.

Correct Answer: D

Rationale: Eyedrops are administered into the lower conjunctival sac formed by pulling the lower eyelid down ensuring medication spreads across the eye evenly when the patient blinks. This maximizes absorption and minimizes runoff, critical for efficacy (e.g., glaucoma drops). The inner canthus (near the nose) risks drainage into the tear duct, reducing dose and potentially causing systemic effects. 'Other canthus' likely means outer canthus (lateral), less effective for retention, as it's not a sac. The upper conjunctival sac is harder to access, requiring awkward lid lifting, and less practical. The lower sac's anatomical suitability holding drops naturally makes it the standard site, ensuring therapeutic delivery and patient comfort, per ophthalmic administration protocols.