Nokea
In assessing the client's chest, which position best shows chest expansion as well as its movements?
- A. Sitting
- B. Prone
- C. Sidelying
- D. Supine
Correct Answer: A
Rationale: The correct answer is A: Sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B, Prone, is incorrect as lying face down would not provide a clear view of chest expansion. Choice C, Sidelying, is also incorrect as this position may limit the visibility of chest movements. Choice D, Supine, is not the best position for assessing chest expansion as it may not offer a clear observation of chest movements during breathing.
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The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse's priority intervention?
- A. Escort the client to the physical therapy department
- B. Medicate the client 30 minutes before going to the whirlpool
- C. Obtain the sterile dressing supplies for the client
- D. Assist the client to the bathroom prior to the treatment
Correct Answer: B
Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client's comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (choice A) is not the priority at this time. While obtaining sterile dressing supplies (choice C) is important, ensuring pain management takes precedence. Assisting the client to the bathroom (choice D) is not directly related to the priority intervention of pain management before the whirlpool treatment.
When does the nurse act as a client advocate?
- A. Pulling the curtain around the client's bed while changing a dressing
- B. Contacting the health care provider to request a meeting for the client
- C. Ensuring access to medical information by appropriate personnel only
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, 'All of the above.' Acting as a client advocate involves various actions to protect the client's rights and well-being. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity. Contacting the health care provider to request a meeting for the client facilitates communication and addresses the client's needs. Ensuring access to medical information by appropriate personnel only safeguards the client's confidentiality and privacy. Therefore, all the actions mentioned in choices A, B, and C are examples of a nurse acting as a client advocate, making D the correct answer.
The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?
- A. "I should increase fruits, bran, and fluids in my diet."
- B. "I will use warm compresses and take sitz baths daily."
- C. "I must take a laxative every night and have a stool daily."
- D. "I can use an analgesic ointment or suppository for pain."
Correct Answer: C
Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.
The HCP orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first two (2) specimens?
- A. Collect the first 15 mL in one jar and then the next 50 mL in another
- B. Collect three (3) early morning, clean voided urine specimens
- C. Collect the specimens after the HCP massages the prostate
- D. Collect a routine urine specimen for analysis
Correct Answer: A
Rationale: To obtain accurate cultures of urethral and bladder urine, the nurse should instruct the patient to collect the first 15 mL of urine in one container and the subsequent 50 mL in another. This method ensures that the specimens are separated appropriately for analysis. Choices B, C, and D are incorrect because collecting three early morning urine specimens, massaging the prostate, or collecting a routine urine specimen would not provide the specific separation of urethral and bladder urine required for this particular test.
Which of the following drugs may cause weight gain?
- A. Amphetamines
- B. Steroids
- C. Antibiotics
- D. Nonsteroidal anti-inflammatory drugs
Correct Answer: B
Rationale: The correct answer is B, Steroids. Steroids are known to cause weight gain as a side effect. Amphetamines, choice A, are more likely to cause appetite suppression and weight loss. Antibiotics, choice C, and nonsteroidal anti-inflammatory drugs, choice D, are not typically associated with weight gain as a common side effect.