The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? (Select all that apply)
Auscultating lung sounds
Obtaining the client’s temperature
Assessing the strength of peripheral pulses
Obtaining information about the client’s respirations
Asking the client about a family history of any illness or disease
Correct Answer : A,B,D
A. Auscultating lung sounds:
Auscultating lung sounds is essential to assess for any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can provide information about the extent and nature of lung congestion.
B. Obtaining the client’s temperature:
Obtaining the client's temperature is important to assess for the presence of fever, which is a common symptom associated with respiratory infections.
C. Assessing the strength of peripheral pulses:
Assessing peripheral pulses is not directly related to cold, cough, and lung congestion symptoms. This type of assessment is more relevant in cardiovascular or peripheral vascular assessments.
D. Obtaining information about the client’s respirations:
Assessing the rate, depth, and rhythm of respirations is crucial when dealing with respiratory symptoms. This information helps determine the severity and nature of the respiratory distress.
E. Asking the client about a family history of any illness or disease:
Family history is important for a comprehensive health assessment, but for the focused assessment of a cold, cough, and lung congestion, obtaining information about the current symptoms and associated factors takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Validate the finding:
Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.
B. Document the finding:
Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.
C. Inform the surgeon:
If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.
D. Inform the charge nurse:
Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.
Correct Answer is ["45"]
Explanation
To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:
mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL
Plugging in the values from the question, we get:
mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL
Simplifying the equation, we get:
mL to administer = 60 mEq x 15 mL / 20 mEq
mL to administer = 45 mL
Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.
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