Nokea
A client with chronic obstructive pulmonary disease is being taught by a nurse about ways to facilitate eating. Which of the following statements indicates a need for further teaching?
- A. I will rest for at least 30 minutes before eating.
- B. I will take my bronchodilators after meals.
- C. I will eat five or six small meals each day.
- D. I will choose foods that are not gas-forming.
Correct Answer: B
Rationale: The correct answer is B: "I will take my bronchodilators after meals." Taking bronchodilators after meals can decrease their effectiveness due to delayed absorption. Step 1: Bronchodilators should be taken before meals to open airways for better breathing. Step 2: Resting before meals (A) can reduce shortness of breath. Eating small meals (C) can prevent overeating and aid digestion. Choosing non-gas forming foods (D) can reduce bloating.
You may also like to solve these questions
Which standardized nursing terminologies specifically relate to the steps of the nursing process (select all that apply)?
- A. Omaha System
- B. Nursing Outcomes Classification (NOC)
- C. Nursing Interventions Classification (NIC)
- D. NANDA International: Nursing Diagnoses
Correct Answer: B
Rationale: NOC, NIC, and NANDA International directly correspond to the steps of the nursing process: outcomes, interventions, and diagnoses.
A 29-year-old client is admitted for a hysterectomy and is expressing concern regarding the procedure. Shortly into the preoperative teaching, the client complains of a tightness in the chest, feelings of suffocation, light-headedness, and tingling in the hands. The client's respirations are rapid and deep. The nursing assessment reveals that this client is:
- A. having a heart attack.
- B. wanting attention from the nurses.
- C. suffering from complete upper airway obstruction.
- D. hyperventilating.
Correct Answer: D
Rationale: Classic symptoms of a heart attack include a heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may also be present. However, the client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, lack of airflow between the nose and mouth, and absent breath sounds. A tightness in the chest, feelings of suffocation, light-headedness, tingling in the hands, and rapid deep respirations are signs and symptoms of hyperventilation, which is almost always a manifestation of anxiety.
Mrs. Blakely had an intracapsular extraction yesterday. Early this morning she complained of eye pain and nausea after breakfast while continuing to complain of eye pain. Your analysis of the situation is that Mrs. Blakely is
- A. unable to tolerate a regular diet this soon postoperatively
- B. allergic to the pain medication
- C. experiencing increased intraocular pressure
- D. exhibiting symptoms of postoperative infection
Correct Answer: C
Rationale: Severe eye pain accompanied by nausea following cataract surgery suggests elevated intraocular pressure, which must be addressed promptly to prevent complications.
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For
which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Stridor. Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction and impending respiratory distress, which is a life-threatening complication of anaphylaxis. The nurse should intervene first by ensuring a patent airway to prevent respiratory compromise. Urticaria (A) is a common symptom of an allergic reaction but does not pose an immediate threat to airway patency. Vomiting (C) can be a sign of gastrointestinal distress but does not require immediate intervention for airway protection. Hypotension (D) is a serious manifestation of anaphylaxis but addressing airway obstruction takes precedence to prevent respiratory failure.
Which drainage is drained with a Hemovac?
- A. Bile
- B. Urine
- C. Gastric contents
- D. Wound drainage
Correct Answer: D
Rationale: Hemovacs are used for wound drainage, collecting serosanguinous fluid.