Adult Health Exam 1 Chamberlain

Correct Answer: C

Rationale: The most important instruction the nurse should provide to a client with COPD prescribed oxygen therapy is not to adjust the oxygen flow rate without consulting a healthcare provider. This is crucial because too much oxygen can suppress the client's respiratory drive, leading to further complications. Choice A is incorrect because increasing the oxygen flow rate without medical advice can be harmful. Choice B is incorrect as oxygen therapy should be used as prescribed, not just when symptoms occur. Choice D is incorrect as the priority is to ensure the correct oxygen flow rate rather than using a humidifier.

Correct Answer: C

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults due to its muscle mass and lower risk of nerve injury. The deltoid muscle is more commonly used for vaccines in adults, the vastus lateralis muscle is preferred in infants and young children, and the dorsogluteal muscle is associated with a higher risk of nerve injury and is no longer recommended for intramuscular injections.

Correct Answer: C

Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.

Correct Answer: A

Rationale: Correct! Monitoring INR is essential in clients on anticoagulant therapy to ensure the blood's clotting time is within the therapeutic range, preventing further embolic events or excessive bleeding. Monitoring blood glucose levels (Choice B), blood pressure (Choice C), and temperature (Choice D) is important for various other conditions but is not directly related to anticoagulant therapy for a client with a history of pulmonary embolism.

Correct Answer: A

Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.