A 58-year-old patient is going home today. The nurse does her final assessment of the patient. Which of the following would be considered a normal finding?
Bowel sounds 5-30 per minute.
Capillary refill of greater than 3 seconds.
Respiratory rate of 25
Heart rate of 10
The Correct Answer is C
The normal range for respiratory rate in adults is typically between 12 to 20 breaths per minute, butsome individuals may have a slightly higher or lower respiratory rate within the normal range.
Options a and b are incorrect. Bowel sounds of 5-30 per minute are within the normal range, but this finding alone does not indicate that the patient is ready to go home. Capillary refill of greater than 3 seconds is considered abnormal and may indicate poor peripheral perfusion.
Option d is also incorrect. A heart rate of 10 is extremely low and would be considered bradycardia. This could indicate an underlying medical issue and would require further assessment and intervention before the patient is discharged.
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Related Questions
Correct Answer is D
Explanation
This response demonstrates respect for the client's religious beliefs and a willingness to work with the client to meet their needs. It also opens up a dialogue between the nurse and the client to develop a plan of care that is consistent with the client's beliefs and values.
Option a, "Fasting is harmful to your body," is not an appropriate response as it does not respect the client's religious beliefs and may be perceived as insensitive or disrespectful.
Option b, "You must have food during times of illness," may be accurate in some situations, but it is not relevant to the client's request to fast during Ramadan.
Option c, "I will let your healthcare provider know that you need to be discharged," is not an appropriate response as it does not address the client's request to fast during Ramadan and may be perceived as dismissive or unhelpful.
Correct Answer is B
Explanation
A.This option is appropriate for children under the age of 3. Pulling the pinna down and back straightens the ear canal in young children, but it does not align the canal correctly in adults.
B.For an adult, the correct method to straighten the ear canal during examination is to pull the pinna (outer part of the ear) up and back. This maneuver aligns the ear canal for better visualization of the tympanic membrane (eardrum) and inner structures.
C.Pulling the pinna down and forward is incorrect for both adults and children. This action would not provide a clear view of the ear canal and could make examination difficult.
D.Pulling the pinna straight back does not fully straighten the ear canal in adults and may make the examination less effective. The correct technique is up and back for adults to fully straighten the canal and enhance visualization.
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