Answer to Question 1
B
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A The nursing diagnosis, Knowledge deficit regarding impending surgery, does not indicate a need to postpone teaching. A knowledge deficit reinforces the need for teaching.
B Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate. The nursing diagnosis of Activity intolerance related to pain indicates a need to postpone teaching. Teaching can be delayed until the nursing diagnosis is resolved or the health problem is controlled.
C The nursing diagnosis of Ineffective management of treatment regimen does not indicate a need to postpone teaching. Ineffective management of treatment regimen reinforces the need for teaching.
D The nursing diagnosis of Noncompliance with prescribed exercise plan does not indicate a need to postpone teaching. The patient who is noncompliant may require further teaching.
Answer to Question 2
C
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A Stress may increase an individual's respiratory depth and rate as a result of sympathetic stimulation.
B Lying flat prevents full chest expansion.
C The first action the nurse should take is to assess the patient's respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it with the previous measurement to determine if the patient is breathing faster than before.
D The nurse should count the respirations. Based on these findings, the nurse may or may not need to take the patient's pulse. Assessing the pulse will not verify whether the patient is breathing faster than before.
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