Nokea
A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.
- A. After I apply the stocking, I roll the top back down about 2 inches to hold the stockings in place.
- B. I remove the stocking and reapply about every day or two.
- C. To apply, I turn the stocking inside out while holding onto the toe.
- D. I apply a small amount of baby powder to my legs before applying the stockings.
- E. These stockings help prevent blood clots.
Correct Answer: A,B,D
Rationale: Rolling the top down (A) can impede circulation, removing stockings every 1-2 days (B) is too infrequent (should be every 8 hours), and baby powder (D) can cause skin irritation. Turning the stocking inside out (C) and preventing clots (E) are correct.
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The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement by the client would indicate effective teaching?
- A. I should inhale through my mouth.'
- B. I should tighten my abdominal muscles with inhalation.'
- C. I should contract my abdominal muscles with exhalation.'
- D. I should make inhalation twice as long as exhalation.'
Correct Answer: C
Rationale: Pursed-lip breathing involves inhaling through the nose and exhaling slowly through pursed lips, which may involve contracting abdominal muscles to assist with exhalation, prolonging exhalation to reduce air trapping in COPD.
The nurse administers ciproflaxin to a client and then realizes that the client is allergic to the medication. What nursing action is the priority for this client?
- A. induce vomiting
- B. obtain the client's vital signs
- C. complete an incident report
- D. notify the health care provider
Correct Answer: D
Rationale: Notifying the health care provider is the priority to initiate immediate management of a potential allergic reaction, followed by monitoring and reporting.
The first exercise that should be performed by the client who had a mastectomy 1 day earlier is:
- A. Walking the hand up the wall
- B. Sweeping the floor
- C. Combing her hair
- D. Squeezing a ball
Correct Answer: D
Rationale: Squeezing a ball is a gentle initial exercise to restore arm mobility.
The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?
- A. Low calorie, low carbohydrate
- B. High calorie, low fat
- C. High protein, high fat
- D. Low protein, high carbohydrate
Correct Answer: B
Rationale: A high-calorie, low-fat diet is suitable post-acute pancreatitis to support recovery while minimizing pancreatic stimulation.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.