Nokea
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler's.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The high lithotomy position, used for procedures like vaginal hysterectomy, involves legs elevated in stirrups, as likely depicted in the figure, and should be documented accurately.
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A 62-year-old male is dying from metastatic lung cancer, and all treatments have been discontinued. The client's breathing pattern is labored, with gurgling. The client's wife asks the nurse, 'Can't you do something to help with his breathing?' Which of the following is the nurse's best response in this situation?
- A. Direct the unlicensed personnel to assess the client's vital signs and provide oral care.
- B. Suction the client so that the client's wife knows all interventions were performed.
- C. Reposition the client, elevate the head of the bed, and provide a cool compress.
- D. Explain to the wife that it is standard practice not to suction clients when treatments have been discontinued.
Correct Answer: C
Rationale: Repositioning, elevating the head of the bed, and using a cool compress can alleviate labored breathing and gurgling (death rattle) in a dying client, providing comfort without invasive measures.
A client with angina has been taking nifedipine. The nurse should teach the client to:
- A. Monitor blood pressure monthly.
- B. Perform daily weights.
- C. Inspect gums daily.
- D. Limit intake of green leafy vegetables.
Correct Answer: C
Rationale: Nifedipine, a calcium channel blocker, can cause gingival hyperplasia. Daily gum inspection helps detect this side effect early.
Which of the following complications is associated with mechanical ventilation?
- A. Gastrointestinal hemorrhage.
- B. Immunosuppression.
- C. Increased cardiac output.
- D. Pulmonary emboli.
Correct Answer: D
Rationale: Mechanical ventilation increases the risk of pulmonary emboli due to immobility and hypercoagulability. Gastrointestinal hemorrhage, immunosuppression, and increased cardiac output are less directly related.
What is the nurse's best response to a client with MS experiencing fatigue?
- A. Limit all activities.
- B. Schedule rest periods.
- C. Increase fluid intake.
- D. Avoid all exercise.
Correct Answer: B
Rationale: Scheduling rest periods helps manage fatigue while supporting activity in multiple sclerosis.
The nurse is caring for a client who has been diagnosed with macular degeneration. Which of the following images represent the visual field of a client with macular degeneration?
- A. Qstn 14-A Visual.png
- B. Qstn 14-B Visual.png
- C. Qstn 14-C Visual.png
- D. Qstn 14-D Visual.png
Correct Answer:
Rationale: Macular degeneration causes central vision loss, so the image would show a blurred or dark central area with intact peripheral vision. Specific image selection is not applicable here due to lack of image options.