Nokea
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
- A. It delivers a specific concentration of oxygen constantly.
- B. It delivers the highest concentration of oxygen possible.
- C. It delivers the low concentration of oxygen you need.
- D. It allows you to remove it for a while when it gets uncomfortable.
Correct Answer: C
Rationale: The correct answer is C: It delivers the low concentration of oxygen you need. Nasal cannulas deliver a low flow rate of oxygen, typically between 1-6 liters per minute, providing a lower concentration of oxygen compared to other oxygen delivery devices. This is suitable for clients who require only a slight increase in their oxygen levels. Choice A is incorrect as nasal cannulas do not deliver a specific concentration of oxygen constantly. Choice B is incorrect as nasal cannulas do not deliver the highest concentration of oxygen possible. Choice D is incorrect because nasal cannulas should not be removed when uncomfortable as it disrupts the oxygen therapy.
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A nurse is reinforcing dietary teaching with a client who wants to reduce solid fat intake. Which of the following instructions should the nurse include?
- A. Replace tub margarine with stick margarine.
- B. Use safflower oil instead of butter when baking.
- C. Consume 2% or whole milk.
- D. Choose ground beef that is at least 80% lean meat.
Correct Answer: B
Rationale: The correct answer is B: Use safflower oil instead of butter when baking. Safflower oil is a healthier alternative to butter as it is a liquid fat and contains unsaturated fats, which are better for heart health and reducing solid fat intake. Butter, on the other hand, is a solid fat high in saturated fats, which can increase cholesterol levels. This substitution promotes a lower intake of solid fats while still allowing for baking needs. The other choices are incorrect because: A) Stick margarine is also a solid fat high in trans fats, not suitable for reducing solid fat intake. C) Whole milk contains solid fats, so opting for low-fat or skim milk would be better. D) Ground beef with at least 80% lean meat still contains solid fats, so choosing leaner options like 90% lean or ground turkey would be more beneficial.
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
- A. Diaphoresis
- B. Retractions
- C. Cyanosis
- D. Restlessness
Correct Answer: D
Rationale: Restlessness is an early sign of inadequate oxygenation, indicating the body's attempt to compensate for low oxygen levels.
A nurse is instructing a client about postural drainage. The nurse should have the client lie on his stomach with his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: D
Rationale: Prone Trendelenburg position aids in secretion clearance from posterior lung segments.
A nurse is collecting data from a client's skin. Which of the following actions should the nurse take to assess skin turgor?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size red or purple spots.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: The correct answer is D: Grasp a fold of skin on the client's forearm or near the sternum. This method assesses skin turgor by evaluating how quickly the skin returns to its normal position after being pinched. Adequate skin turgor indicates good hydration status, as hydrated skin will snap back promptly. If the skin remains elevated or "tents," it may indicate dehydration. Choice A involves palpation, which assesses skin temperature and texture but not turgor. Choice B involves assessing edema, not skin turgor. Choice C describes petechiae, which are indicative of bleeding disorders. Overall, choice D is the most appropriate for assessing skin turgor accurately.
A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.