Nokea
A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?
- A. Use incentive spirometer every 4 hours while awake.
- B. Initiate ambulation after discontinuing the NG tube.
- C. Maintain a supine position with an abdominal binder.
- D. Splint the incision to support coughing every 2 hours.
Correct Answer: D
Rationale: The correct answer is D because splinting the incision supports coughing, which helps clear secretions and prevents respiratory complications. It is essential postoperatively to prevent atelectasis and pneumonia. Using an incentive spirometer (A) aids in lung expansion but does not directly support coughing. Ambulation (B) promotes circulation but does not address respiratory concerns. Maintaining a supine position with an abdominal binder (C) may restrict diaphragmatic movement and increase the risk of respiratory complications.
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What is first-line therapy for insomnia?
- A. Complementary therapies such as melatonin
- B. Cognitive-behavioral therapies such as relaxation therapy
- C. Benzodiazepine-receptor-like agents (e.g., zolpidem [Ambien])
- D. Over-the-counter medication such as diphenhydramine (Benadryl)
Correct Answer: B
Rationale: The correct answer is B. Cognitive-behavioral therapy (CBT) is the first-line treatment for insomnia due to its effectiveness and lack of side effects. Melatonin (A) and over-the-counter medications (D) are secondary options, while benzodiazepines (C) are reserved for short-term use.
What should be included in Mr. Ross’s plan of care during radiation therapy if he complains of weakness and lethargy?
- A. Encouraging him to rest more than usual
- B. Monitoring his intake and output
- C. Helping him to accept his condition
- D. Checking his blood pressure daily
Correct Answer: A
Rationale: Rest conserves energy and aids recovery during radiation therapy.
9. When the family members of a postoperative patient leave after a visit, the patient tells the nurse that his family gave him a headache by fussing over him so much. What is an appropriate intervention by the nurse?
- A. Administer the PRN analgesic prescribed for his postoperative pain.
- B. Ask the patient’s permission to use acupressure to ease his headache.
- C. Reassure the patient that his headache will subside now that his family has gone.
- D. Teach the patient biofeedback methods to relieve his headaches by controlling cerebral blood flow.
Correct Answer: B
Rationale: Asking the patient’s permission to use acupressure (option B) is an appropriate non-pharmacological intervention that respects patient autonomy and may effectively alleviate the headache.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.
Exercise can improve circulation and cardiovascular fitness by decreasing
- A. The number of small blood vessels throughout the body
- B. The heart rate and blood pressure
- C. High-density lipoproteins (HDL) in the blood
- D. The body’s breathing capacity
Correct Answer: B
Rationale: The correct answer is B because exercise can improve circulation and cardiovascular fitness by reducing the heart rate and blood pressure. When we exercise, our heart becomes more efficient at pumping blood, leading to a lower resting heart rate and reduced blood pressure. This helps improve circulation and strengthens the cardiovascular system.
Explanation for why the other choices are incorrect:
A: The number of small blood vessels throughout the body - Exercise actually promotes the growth of new blood vessels, improving circulation.
C: High-density lipoproteins (HDL) in the blood - Exercise can increase HDL levels, which is beneficial for heart health.
D: The body’s breathing capacity - Exercise can improve lung function and increase breathing capacity, but it is not directly related to circulation or cardiovascular fitness.