Nokea
A client scheduled for a Nissen repair for a hiatal hernia is being instructed preoperatively to use the incentive spirometer. The nurse determines that the client has understood the teaching when the client states:
- A. These exercises will help to decrease my pain.
- B. I should use this device once a day.
- C. If I use this device, it will help in preventing pneumonia.
- D. I should do these breathing techniques while lying down flat in bed.
Correct Answer: C
Rationale: Incentive spirometry's purpose is to prevent or treat atelectasis, which can lead to pneumonia. Answer A is a false statement, so it is incorrect. Answer B is incorrect because the timing is not as often as it should be. Answer D is wrong because it is best done sitting upright.
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The nurse is performing a sterile dressing change. Which action is essential?
- A. Touching the corners of the dressing with clean gloves
- B. Discussing the wound with the client during the dressing change
- C. Irrigating the wound with an antiseptic solution
- D. Wearing sterile gloves during the dressing change
Correct Answer: D
Rationale: Wearing sterile gloves maintains a sterile field, essential for preventing infection during a sterile dressing change.
Which of the following describes the proximodistal development in the infant?
- A. The infant is able to raise his head before he is able to sit.
- B. The infant can control movements of his arms before he can control movements of his fingers.
- C. The infant responds to pain with his whole body before he can localize pain.
- D. The infant is able to make rudimentary vocalizations before using spoken words.
Correct Answer: B
Rationale: Proximodistal development refers to motor control progressing from the center of the body outward, meaning infants gain control of larger muscles (arms) before finer muscles (fingers).
The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with
- A. aggressive behaviors and angry feelings.
- B. self-identity and self-esteem.
- C. focusing on reality.
- D. family boundary intrusions.
Correct Answer: B
Rationale: clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do
The home nurse who is caring for an older person who has chronic obstructive pulmonary disease (COPD) with continuous nasal oxygen is helping the family set up a humidifier in the room. The humidifier cord is not long enough to reach the outlet in the room and must be plugged into an extension cord. The extension cord is wrapped with black tape. When the nurse asks the family members about the tape, they reply that the cord is an old cord, and the electrical tape covers up the frayed part and makes it safe. They say a contractor friend told them how to make it safe. How should the nurse respond?
- A. Refuse to set up the equipment until a new cord is available
- B. Carefully inspect the taped area and set up equipment if it appears intact
- C. Ask the family to let the nurse discuss the safety of the cord with the contractor friend
- D. Set up the equipment and suggest that the family get a new extension cord as soon as possible
Correct Answer: A
Rationale: A frayed cord poses a fire hazard, especially with oxygen use. Refusing to set up until a safe cord is available prioritizes safety.
The nurse is caring for a woman who had a mastectomy following a diagnosis of breast cancer. When the nurse enters the room, the curtains are drawn, and the client is lying with her body turned toward the wall away from the nurse. When the nurse approaches her, the client says, 'Just leave me alone. I'm no use to anyone. I'm not even a real woman.' How should the nurse respond?
- A. Leave the room
- B. Open the curtains
- C. Say, 'You sound upset.'
- D. Say, 'Women are more than breasts.'
Correct Answer: C
Rationale: Acknowledging the client's feelings is an appropriate response to this common grief reaction following the loss of a body part. Leaving the room would reinforce the client's perception that she is useless. Opening the curtains does not address the client's concerns; it merely forces the nurse's perception of appropriateness on the client. Saying 'Women are more than breasts' is not an appropriate response to the client. The nurse should recognize the client's feelings, not put her down.