Nokea
A nurse is performing chest physiotherapy for a client with a respiratory infection. Which of the following techniques should the nurse use to increase the velocity and turbulence of the air the client exhales?
- A. Postural drainage
- B. Nebulization
- C. Percussion
- D. Vibration
Correct Answer: D
Rationale: Vibration increases air turbulence and helps loosen secretions, facilitating expectoration.
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A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
- A. Lower the height of the solution container.
- B. Encourage the client to bear down.
- C. Allow the client to expel some fluid before continuing.
- D. Stop the enema and document that the client did not tolerate the procedure.
Correct Answer: A
Rationale: Correct Answer: A: Lower the height of the solution container.
Rationale: Lowering the height of the solution container will decrease the rate of flow, reducing the pressure and volume of the solution entering the client's colon. This can help alleviate the cramping sensation by slowing down the administration of the enema.
Summary of other choices:
B: Encouraging the client to bear down may increase intra-abdominal pressure, worsening the cramping sensation.
C: Allowing the client to expel some fluid before continuing may not address the root cause of the discomfort, which is the rapid influx of solution.
D: Stopping the enema and documenting that the client did not tolerate the procedure does not actively address the client's discomfort or provide immediate relief.
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
- A. Provide support by holding the client's arm.
- B. Lean the client toward the wall.
- C. Lower the client to the floor.
- D. Maintain a narrow base of support.
Correct Answer: C
Rationale: The correct action for the nurse to take when a client begins to fall during ambulation is to lower the client to the floor (Choice C). This is the safest option to prevent further injury to the client. Lowering the client to the floor helps minimize the distance of the fall, reducing the risk of serious injury. Additionally, it allows for a controlled descent, ensuring the client lands safely. Providing support by holding the client's arm (Choice A) may not be enough to prevent a fall and could lead to both the nurse and the client getting injured. Leaning the client toward the wall (Choice B) may not provide adequate support and could still result in a fall. Maintaining a narrow base of support (Choice D) may not be effective in preventing a fall. The best course of action is to prioritize the safety of the client by lowering them to the floor in a controlled manner.
A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test (FOBT). Which of the following should the nurse instruct the client to avoid for at least 3 days before the test?
- A. Whole grain cereal
- B. Magnesium hydroxide
- C. Orange juice
- D. Acetaminophen
Correct Answer: B
Rationale: The correct answer is B: Magnesium hydroxide. This is because magnesium hydroxide, commonly found in antacids and laxatives, can cause false-positive results in a fecal occult blood test (FOBT) due to its chemical reaction with the test reagents. Instructing the client to avoid magnesium hydroxide for at least 3 days before the test ensures accurate results.
Incorrect choices:
A: Whole grain cereal - Whole grain cereal does not interfere with FOBT results.
C: Orange juice - Orange juice does not impact FOBT results.
D: Acetaminophen - Acetaminophen does not affect FOBT results.
Therefore, avoiding magnesium hydroxide is crucial to obtaining reliable results in the FOBT.
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important as it allows the family to have closure, grieve, and say their goodbyes in a respectful and private manner. It also promotes a sense of dignity and respect for the deceased. Choice A is incorrect as it may delay the family's grieving process. Choice B is incorrect as postmortem care should be performed after the family has had a chance to view the body. Choice C may be helpful but is not as essential as allowing the family to view the body privately.