Where should a nurse auscultate the apex beat?

Correct Answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

Correct Answer: D

Rationale: The correct answer is D. A medical record becomes a potential issue for a doctor or a nurse when it is inaccurate, incomplete, or inadequate. This is because a medical record is a key tool for healthcare professionals to track a patient's history, treatment, and progress. If the record is not accurate or complete, it can lead to misdiagnosis, incorrect treatment, or other potential problems in patient care. While missing records (Choice C) could be a problem, they do not directly implicate the doctor or nurse in the same way that inaccurate or inadequate records do. An extensive record (Choice A) or a record being subpoenaed in court (Choice B) are not inherently problematic for healthcare professionals and do not necessarily reflect negatively on their work.

Correct Answer: A

Rationale: The correct answer is A, 'Monitoring a respiratory rate of 16 to 20 per minute'. When performing postural drainage and percussion, it is crucial to monitor the respiratory rate to ensure the safety and effectiveness of the procedure. Choice B, 'Assessing the client's ability to tolerate sitting and lying positions', while important, is not directly related to the specifics of postural drainage and percussion. Similarly, option C, 'Ensuring the client is free of signs of infection', although important, is not directly linked to the procedure. Option D, 'Knowing the time of the client's last food and fluid intake', might be relevant for other procedures, but it is not the primary consideration for postural drainage and percussion.

Correct Answer: C

Rationale: In the context of pediatric care, a respiratory rate of more than 60 breaths per minute in a child aged 13 months is considered fast breathing, hence option 'C' is correct. Options 'A', 'B', and 'D' are incorrect as they do not meet the specified criteria for fast breathing in a 13-month-old. Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, including monitoring respiratory rates, to ensure that interventions are appropriately targeted and outcomes are optimized.

Correct Answer: D

Rationale: The correct answer is 'Termination'. This phase of the therapeutic relationship is when the nurse informs the patient about the conclusion of therapy. It is during this phase that the nurse and the patient review the goals and progress made and also discuss the upcoming termination. The other phases are not the appropriate times for discussing termination. 'Pre-orientation' is the phase before the nurse-patient relationship is established; 'Orientation' is when the nurse and patient get to know each other and set goals; and 'Working' is when these goals are pursued. Therefore, choices A, B, and C are incorrect.

Correct Answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

Correct Answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

Correct Answer: B

Rationale: The correct answer is B, as it emphasizes the importance of hygiene in food handling, which is crucial to prevent the spread of germs and diseases. The other options do not address the root of the issue, which is the unhygienic handling of food. Option A avoids direct confrontation but does not educate the vendor on proper hygiene. Option C, although it suggests a hygienic method, may not be practical or available in all situations. Option D is an avoidance strategy rather than a way to address the problem.

Correct Answer: A

Rationale: An anemic patient would benefit from increasing their intake of beef. Beef is an excellent source of heme iron, which is critical for treating anemia. Heme iron is absorbed more readily by the body compared to non-heme iron found in plant-based foods. Apples and white bread, while healthy, do not contain significant amounts of heme iron. Fish, although it does contain iron, it's non-heme iron, which is not as efficiently absorbed by the body as heme iron, hence less effective in treating anemia.