While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.
Packs of cigarettes smoked per day.
Number of attempts to quit smoking.
Client’s current age.
Age when the client started smoking.
Number of years the client smoked.
Correct Answer : A,D,E
Choice A rationale
Packs of cigarettes smoked per day is essential information for calculating smoking pack years.
Choice B rationale
The number of attempts to quit smoking is not required for calculating smoking pack years.
Choice C rationale
The client’s current age is not required for calculating smoking pack years.
Choice D rationale
The age when the client started smoking is necessary to determine the total number of years smoked.
Choice E rationale
The number of years the client smoked is essential for calculating smoking pack years.
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Correct Answer is C
Explanation
Choice A rationale
Asking the client to complete a common proverb or saying can provide some insight into cognitive function and language skills, but it may not comprehensively assess speech patterns. This method may also be influenced by the client’s familiarity with specific proverbs.
Choice B rationale
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.
Choice C rationale
Noting the client’s responses during the initial interview allows the nurse to observe the client’s spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. This approach provides a comprehensive assessment of speech abilities in various contexts.
Choice D rationale
Listening while the client reads items listed on the menu can assess reading ability and pronunciation, but it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.
Correct Answer is A
Explanation
Choice A rationale: Administering oxygen via nasal cannula is the first priority in this scenario. The client’s oxygen saturation is 88% on room air, which indicates hypoxemia. Providing supplemental oxygen will help improve the client’s oxygenation and alleviate symptoms of shortness of breath. Ensuring adequate oxygenation is crucial to prevent further respiratory distress and potential complications.
Choice B rationale: Obtaining a sputum culture is important to identify the causative organism of the client’s respiratory infection and guide appropriate antibiotic therapy. However, this action is not the immediate priority. Addressing the client’s hypoxemia by administering oxygen takes precedence to stabilize the client’s condition.
Choice C rationale: Administering an antipyretic medication can help reduce the client’s fever and improve comfort. However, this is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen.
Choice D rationale: Encouraging the client to increase fluid intake is important for maintaining hydration and helping to thin respiratory secretions. However, this action is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen