Which of the following are appropriate when assessing a client's respiration?

Correct Answer: B

Rationale: In assessing a client's respiration, placing the client in a semi-Fowler's position (option B) is the most appropriate choice. This position allows for optimal chest expansion and lung ventilation, making it easier to observe and count the respiratory rate accurately. Placing the stethoscope on the anterior chest (option D) is not necessary for routine respiratory rate assessment and may not provide additional relevant information. Counting the respiratory rate for 1 minute (option A) is a standard practice, but it does not address the positioning of the client, which is crucial for an accurate assessment. Counting the respiratory rate simultaneously with the pulse (option C) can be challenging and may lead to inaccurate readings due to potential distractions. It is essential to prioritize respiratory assessment as a separate and focused task to ensure accuracy. In an educational context, understanding the importance of proper client positioning during respiratory assessment is fundamental for nursing students. By learning the rationale behind positioning choices, students can develop critical thinking skills and improve their assessment techniques. Emphasizing the significance of accurate respiratory assessments can help students provide quality care and make informed clinical decisions in their future nursing practice.

Correct Answer: B

Rationale: The correct answer is B) to ensure knowledgeable, safe, comprehensive nursing care. The primary purpose of standards of nursing practice is to ensure that nurses deliver high-quality care that is safe, knowledgeable, and comprehensive. These standards outline the expectations for professional behavior, competence, and quality of care provision. By adhering to these standards, nurses can guarantee that they are providing the best possible care to their patients, maintaining their safety and well-being. Option A) is incorrect because while standards do encompass safe performance of skills, their primary purpose is broader and includes more than just skill performance. Option C) is incorrect because while standards do establish nursing as a profession and discipline, their main goal is to guide the delivery of care. Option D) is incorrect as standards primarily focus on the quality of care provided, rather than advocacy or policy-making. In an educational context, understanding the purpose of nursing standards is crucial for students to grasp the foundational principles of nursing practice. By recognizing the significance of these standards, students can appreciate the importance of adhering to them throughout their nursing careers to ensure optimal patient outcomes and uphold the integrity of the nursing profession.

Correct Answer: C

Rationale: Rationale: 1. The convalescent period starts when the patient leaves the recovery room after surgery. 2. It ends when the patient is discharged from the hospital. 3. This period includes recovery, monitoring, and post-operative care. 4. Choice A is incorrect as it only considers the transfer time. 5. Choice B is incorrect as it focuses solely on the recovery from anesthesia. 6. Choice D is incorrect as it excludes the crucial recovery room period. Summary: The correct answer is C because it accurately defines the post-operative convalescent period from leaving the recovery room to hospital discharge, encompassing the entire post-operative care process.

Correct Answer: D

Rationale: The correct answer is D because nitroglycerin is a vasodilator that works by dilating veins, reducing venous return to the heart, and subsequently decreasing preload. By decreasing preload, nitroglycerin reduces the work the heart has to do, which helps relieve angina symptoms. A is incorrect because nitroglycerin does not increase contractility or slow heart rate. B is incorrect because nitroglycerin does not increase AV conduction or heart rate. C is incorrect because nitroglycerin does not decrease contractility or oxygen consumption. In summary, the key mechanism of action of nitroglycerin is reducing venous return through vasodilation, leading to decreased preload and relief of angina symptoms.

Correct Answer: B

Rationale: The correct answer is B: Avoid foods high in vitamin K. Vitamin K can interfere with the effectiveness of anticoagulants. Teaching the client to avoid foods high in vitamin K, such as leafy greens and broccoli, helps maintain the stability of their blood thinning medication. Reporting incidents of diarrhea (choice A) is important for monitoring side effects but not directly related to anticoagulant therapy. Using a straight razor when shaving (choice C) can increase the risk of cuts and bleeding, which is not ideal for someone on anticoagulants. Taking aspirin for pain relief (choice D) is not recommended as it can increase the risk of bleeding when combined with anticoagulants.