Nokea
A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?
- A. Side-lying on the left with the head elevated 10 degrees
- B. Side-lying on the left with the head elevated 35 degrees
- C. Side-lying on the right with the head elevated 10 degrees
- D. Side-lying on the right with the head elevated 35 degrees
Correct Answer: A
Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.
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The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to
- A. Wrap the leg with elastic bandages
- B. Apply pressure at the bleeding site
- C. Reinforce the dressing and elevate the leg
- D. Remove the dressings and re-dress the incision
Correct Answer: B
Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss.
Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding.
Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding.
Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.
A nurse is providing anticipatory guidance to the parents of a newborn about feeding skills. Which of the following is not an infant's feeding skill?
- A. Pushes solid objects from mouth
- B. Eats foods that are higher in fat
- C. Begins experimenting with a spoon
- D. Eats pieces of soft, cooked food
Correct Answer: B
Rationale: The correct answer is B. When discussing infant feeding skills, it is important to note that eating foods higher in fat is not considered a specific feeding skill for newborns. The typical progression of feeding skills includes pushing solid objects from the mouth, eating pieces of soft, cooked food, drinking from a cup held by another person, and experimenting with a spoon. Choices A, C, and D correspond to the expected developmental sequence of feeding skills for infants, making them incorrect answers in this context.
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is:
- A. difference in the intake and output
- B. changes in the mucous membranes
- C. skin turgor
- D. weekly weight
Correct Answer: D
Rationale: In a client with altered renal function, monitoring fluid balance is crucial. Weekly weight is the most accurate indicator of fluid balance during the visits as it reflects cumulative changes in the body's fluid status. Changes in intake and output (Choice A) can provide valuable information, but weekly weight is a more direct measure of overall fluid retention or loss. Changes in mucous membranes (Choice B) and skin turgor (Choice C) can be influenced by factors other than fluid balance, making them less reliable indicators in this context.
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. Exercise by doing weight-bearing activities
- B. Exercise to reduce weight
- C. Avoid exercise activities that increase the risk of fracture
- D. Exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: The most important instruction for a 65-year-old female client diagnosed with osteoporosis regarding exercise is to engage in weight-bearing activities. Weight-bearing exercises are crucial in maintaining bone density and preventing osteoporosis-related fractures. Choice B is incorrect because the primary focus should be on bone health rather than weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture would limit physical activity, which is essential for overall health. Choice D is incorrect as while strengthening muscles is beneficial, weight-bearing activities directly impact bone health in osteoporosis.
During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?
- A. Breath sounds are auscultated bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88%
- D. Client is unable to speak
Correct Answer: C
Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.