Nokea
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status?
- A. Decreased fat intake
- B. Decreased fluid intake
- C. Sleeping soundly during the night
- D. Anxiety about the upcoming pulmonologist visit
Correct Answer: B
Rationale: The client with exacerbation of COPD has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps limit exacerbations of the disease. Decreased fat intake, sleeping soundly, and anxiety related to scheduled pulmonologist visit are not directly associated with this change in condition.
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The nurse has conducted teaching, with a client who experienced pulmonary embolism, about methods to prevent recurrence after discharge. Which client statement demonstrates understanding of the teaching?
- A. I will limit the intake of fluids.
- B. I will sit down whenever possible.
- C. I am planning to continue to wear supportive hose.
- D. I will cross my legs only at the ankle and not at the knees.
Correct Answer: C
Rationale: Wearing supportive hose enhances venous return, reducing the risk of thrombus formation and pulmonary embolism recurrence. Limiting fluid intake can lead to hemoconcentration, increasing clot risk. Prolonged sitting or crossing legs (even at the ankles) can impede venous return and should be avoided.
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.
A mother infected with hepatitis B asks the nurse about the possibility of breastfeeding her neonate. Which response by the nurse would be most appropriate?
- A. Yes, breastfeeding is an acceptable option.
- B. No, you should not breastfeed your baby.
- C. Yes, breastfeeding is an acceptable option once your baby is immunized with the hepatitis B vaccine.
- D. Bottled formula is just as nutritious for your baby.
Correct Answer: C
Rationale: Breastfeeding is safe for hepatitis B-positive mothers if the neonate is vaccinated and receives immunoglobulin, reducing transmission risk.
The nurse has given the client with a nonplaster (fiberglass) leg cast instructions regarding cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?
- A. I should avoid walking on wet, slippery floors.
- B. I'm not supposed to scratch the skin underneath the cast.
- C. It's all right to wipe dirt off of the top of the cast with a damp cloth.
- D. If the cast gets wet, I can dry it with a hair dryer turned to the hot setting.
Correct Answer: D
Rationale: Using a hair dryer on a hot setting to dry a wet fiberglass cast can cause burns or damage the cast. Avoiding slippery floors, not scratching under the cast, and wiping the cast with a damp cloth are correct care instructions.
The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required?
- A. I need to clean the penis every hour with baby wipes.
- B. I need to check for bleeding every hour for the first 12 hours.
- C. My baby will not urinate for the next 24 hours because of swelling.
- D. I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper.
Correct Answer: B
Rationale: After circumcision, the mother needs to be taught to observe for bleeding and assess the site hourly for 8 to 12 hours. Water is used for cleaning because soap or baby wipes may irritate the area and cause discomfort. Voiding needs to be assessed. The mother should call the primary health care provider if the baby has not urinated within 24 hours because swelling or damage may obstruct urine output. When the diaper is changed, Vaseline gauze should be reapplied (if prescribed). Frequent diaper changing prevents contamination of the site.