Nokea
A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.
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A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A: Excessive laxative use can lead to constipation by causing dependency on laxatives. B: Ignoring the urge to defecate can disrupt the normal bowel movement pattern, leading to constipation. C: Inadequate fluid intake can result in hard, dry stools that are difficult to pass, causing constipation. D: Increased fiber in the diet actually helps prevent constipation by adding bulk to the stool. E: Increased activity generally promotes bowel regularity and helps prevent constipation. By discussing A, B, and C with the client, the nurse can address common causes of constipation and provide appropriate interventions.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe Saturday as a holy day of rest and worship, known as the Sabbath. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and practices. This intervention promotes culturally sensitive care by acknowledging and accommodating the client's spiritual needs.
Choice B (Arrange for him to receive the sacrament of the sick) is incorrect as this intervention is specific to the Catholic faith, not Seventh-Day Adventist beliefs. Choice C (Assign same-gender caregivers) is not directly related to the client's religious preferences and may not be necessary for providing culturally sensitive care in this context. Choice D (Offer him a kosher dietary menu) is more aligned with Jewish dietary laws, which do not specifically apply to Seventh-Day Adventist beliefs.
A nurse is caring for a client whose parent has died. The client asks the nurse, 'Why do I feel relief now that my dad is gone?' Which of the following responses should the nurse make?
- A. You should start planning your father's funeral.'
- B. Tell me what you are thinking.'
- C. You are in denial about your father's death.'
- D. Your father is not suffering anymore.'
Correct Answer: B
Rationale: Encouraging the client to express their feelings fosters therapeutic communication and helps with grief processing.
A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow breathing alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A: Breathing ranging from very deep to very shallow with periods of apnea. Cheyne-Stokes respirations are characterized by a cyclical pattern of breathing that starts with shallow breaths and gradually becomes deeper, followed by a period of apnea. This pattern repeats itself. Option B is incorrect because it describes shallow breathing alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Option C describes rapid and deep regular respirations, which is not consistent with Cheyne-Stokes respirations. Option D describes an inability to breathe without dyspnea unless sitting upright, which is not a feature of Cheyne-Stokes respirations. It is important for the nurse to be able to identify this specific respiratory pattern in the older adult client to provide appropriate care and support.
A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?
- A. 3.6 mg/dL
- B. 9 mg/dL
- C. 18.7 mg/dL
- D. 24 mg/dL
Correct Answer: D
Rationale: The correct answer is D: 24 mg/dL. BUN (Blood Urea Nitrogen) levels typically increase in dehydration due to reduced kidney perfusion. A BUN level of 24 mg/dL is higher than normal (7-20 mg/dL) and is indicative of dehydration. Choice A (3.6 mg/dL) is too low for a dehydrated client. Choice B (9 mg/dL) is within the normal range and not high enough for dehydration. Choice C (18.7 mg/dL) is slightly elevated but may not be as indicative of dehydration as choice D.