The nurse reads in the patient chart the doctor's day round note. The doctor writes AOX3, the nurse knows this means the patient is oriented to: Select all that apply.

Background

Person

Situation

Place

Time

Answer and Explanation

Correct Answer : B,D,E

A) Background: Orientation to "background" is not a standard component of the "AOX3" (alert and oriented times three) assessment. Typically, orientation assessments focus on more specific elements such as person, place, and time, rather than background information.
B) Person: Orientation to "person" means that the patient is aware of who they are. This is a key aspect of the AOX3 assessment, which checks whether the patient can identify themselves correctly.
C) Situation: While awareness of the situation or current circumstances is important, "situation" is not included in the standard AOX3 assessment. The usual components are person, place, and time.
D) Place: Orientation to "place" means the patient knows where they are. This is a critical component of the AOX3 assessment, indicating that the patient can identify their current location.
E) Time: Orientation to "time" means that the patient is aware of the current date, day of the week, and time of day. This is another essential part of the AOX3 assessment, reflecting the patient's awareness of the temporal context.

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Correct Answer is A

Explanation

A) Instruct the patient on Tripod positioning: Tripod positioning, where the patient leans forward with hands on their knees or a table, is beneficial for COPD patients. It helps improve ventilation by allowing the diaphragm to work more efficiently and aiding in the expansion of the lungs. This position also utilizes accessory muscles, which can help ease breathing and reduce the work of respiration.
B) Restrict the client's fluid intake to less than 2 L/day: Restricting fluid intake is generally not advisable for COPD patients unless there is a specific condition such as severe heart failure where fluid restriction is necessary. Adequate fluid intake helps to thin mucus, making it easier to expectorate and thus supports better lung function and overall respiratory health.
C) Provide the client with a low-protein diet: COPD patients typically require a higher-protein diet to maintain muscle mass and strength, which are crucial for overall health and respiratory function. A low-protein diet can lead to muscle wasting, including the respiratory muscles, which can worsen respiratory symptoms and functional status.
D) Have the client use the early-morning hours for exercise and activity: While regular exercise is important, the timing should be based on the client's individual preferences and tolerance. For some patients, early morning might not be the best time due to morning symptoms or fatigue. The exercise plan should be customized to fit the patient’s daily routine and energy levels.

A. Pelvic examination B. Transillumination C. Bladder percussion D. Digital rectal examination

Correct Answer is D

Explanation

A. Pelvic examination: A pelvic examination is generally used to assess the reproductive organs in females rather than the prostate. It does not provide a direct assessment of the prostate gland in males.
B. Transillumination: Transillumination is a technique used to detect fluid-filled cysts or masses in areas such as the scrotum or breast. It is not used to assess the prostate gland.
C. Bladder percussion: Bladder percussion is used to assess bladder size and fullness, typically to diagnose conditions related to bladder dysfunction. It does not provide information about the prostate.
D. Digital rectal examination: A digital rectal examination (DRE) is the standard method used to assess the size, shape, and consistency of the prostate gland. It allows the clinician to feel the prostate through the rectal wall and is essential for evaluating prostate health.

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The nurse reads in the patient chart the doctor's day round note. The doctor writes AOX3, the nurse knows this means the patient is oriented to: Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Correct Answer is A

Explanation

Which of the following would the nurse expect to be done to assess the size of the prostate?

Correct Answer is D

Explanation

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