Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

A client demonstrates how to inject insulin into the abdomen

A client attends a course on exercise techniques

A client watches the nurse apply a dressing

A client lists food choices that are considered part of a healthy diet

A client nods when told how to take the blood pressure medication

Answer and Explanation

Correct Answer : A,D

A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.
B. Attending a course does not confirm comprehension or skill.
C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.
D. Listing healthy food choices indicates understanding of dietary education.
E. Nodding does not confirm learning; it may only indicate acknowledgment.

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Correct Answer is C

Explanation

A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.
B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.
C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.
D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.
E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.

A. Decreased lung sounds on expiration B. Respirations are 40 breaths/minute C. Anterior-posterior diameter ratio is 1:1 D. Hyperresonance is noted to percussion E. Decreased tactile fremitus is present

Correct Answer is B

Explanation

A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.

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Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

Correct Answer is C

Explanation

The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

Correct Answer is B

Explanation

The nurse receives orders for an opiate pain medication for a client with severe pain. What other order does the nurse anticipate getting?

In which position would the nurse place a 20 year old adult with asthma who is short of breath?

Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

The nurse is percussing over the lungs of a client with pneumonia. What sound will the nurse expect to hear?

The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally responsive care?

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally responsive care?