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The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?

Asthma

Pneumothorax

Atelectasis

Emphysema

Bronchitis

Answer and Explanation

The Correct Answer is C

A. Asthma typically presents with wheezing, not fine crackles.

B. Pneumothorax usually presents with decreased or absent breath sounds rather than crackles.

C. Atelectasis, which is common after surgery, can cause fine crackles at the lung bases due to collapsed alveoli reopening during inspiration.

D. Emphysema generally results in diminished breath sounds and hyper-resonance rather than crackles.

E. Bronchitis typically produces coarse crackles or rhonchi, not fine crackles.

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A. Provides care that is based on meanings generated by predetermined criteria. B. Provides care that is based on the priorities of the hospital unit workflow. C. Provides care that is the same as the values of the professional health care system. D. Provides care that makes the nurse the leader in determining what is needed. E. Provides care that honors the client's differences and perspectives.

Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may not be responsive to the unique cultural needs of each client.

B. Focusing solely on hospital unit workflow prioritizes efficiency over individualized patient care, which may not respect cultural differences.

C. This approach fails to acknowledge the diverse values and beliefs of clients, which can lead to miscommunication and unmet needs.

D. This implies a top-down approach to care, which may disregard the client’s preferences and cultural context.

E. Honoring the client's differences and perspectives demonstrates the nurse's commitment to culturally responsive care, ensuring that care is tailored to meet the unique needs of each client.

A. 3+ B. 1+ C. 2+ D. +0 E. 4+

Correct Answer is B

Explanation

A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).

B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.

C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).

D. +0 indicates no edema present at all.

E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).

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The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?

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Correct Answer is E

Explanation

Correct Answer is B

Explanation

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Take full exam for free The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?

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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?

Correct Answer is E

Explanation

How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

Correct Answer is B

Explanation

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The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?