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A nurse is reviewing the plan of care for a client who has a respiratory infection. The nurse should plan to have the client lie on his stomach with pillows elevating his chest and stomach 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: C
Rationale: Prone positioning with elevation allows mucus drainage from posterior lung segments.
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A nurse is collecting data from the daughter of an older adult client. Which of the following statements by the daughter is a priority to the nurse?
- A. My mother is unable to bathe herself.'
- B. We sit outside every afternoon.'
- C. We buy the prescriptions we can afford.'
- D. My mother seems depressed.'
Correct Answer: C
Rationale: Financial constraints affecting medication adherence pose an immediate health risk and require intervention.
A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?
- A. Assign the client to a quiet room away from the nurses' station.
- B. Elevate the four side rails on the client's bed at night time.
- C. Encourage the client to rest during the day.
- D. Take the client to the bathroom on a regular schedule.
Correct Answer: D
Rationale: The correct answer is D: Take the client to the bathroom on a regular schedule. This is the most appropriate intervention as older adults with dementia may have difficulty expressing their needs and may forget to use the bathroom. Establishing a routine for bathroom breaks can prevent accidents and promote comfort. Choice A is incorrect as isolating the client may increase agitation. Choice B is incorrect as using all four side rails can be a safety hazard and restrict mobility. Choice C is incorrect as it does not address the specific issue of wandering at night.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop gross motor skills around 2 years old, making riding a tricycle a suitable activity. Jumping rope (choice A) requires more advanced coordination and balance. Printing letters and numbers (choice C) involves fine motor skills that develop later. Using scissors (choice D) also requires more advanced fine motor skills.
A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?
- A. pH 7.31
- B. pH 7.39
- C. pH 7.48
- D. pH 7.50
Correct Answer: A
Rationale: The correct answer is A: pH 7.31. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to decreased pH. Normal pH range is 7.35-7.45. pH 7.31 indicates acidosis. Choice B is within the normal range, C and D are alkalotic, and E, F, G are not provided. pH 7.31 is the most accurate representation of respiratory acidosis in this scenario.
When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
- A. Wrapping the cuff too loosely around the client's arm
- B. Positioning the client's arm above heart level
- C. Measuring blood pressure right after the client's mealtime
- D. Deflating the cuff too slowly
Correct Answer: B
Rationale: The correct answer is B: Positioning the client's arm above heart level. When the client's arm is positioned above heart level, it can lead to an artificially low blood pressure reading due to gravitational effects. This position can cause blood to pool in the arm, reducing the pressure in the arteries and resulting in an inaccurate measurement. This error is known as hydrostatic pressure error. Wrapping the cuff too loosely (choice A) can lead to an inaccurate reading due to inadequate compression of the artery. Measuring blood pressure right after a meal (choice C) can also affect the reading due to the body's response to food intake. Deflating the cuff too slowly (choice D) can result in a falsely elevated diastolic reading.