Nokea
A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Encourage pursed-lip breathing
- C. Position the client in high Fowler's position
- D. Encourage deep breathing and coughing
Correct Answer: B
Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.
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What are the signs and symptoms of fluid overload?
- A. Edema, shortness of breath, weight gain
- B. High blood pressure and jugular venous distention
- C. Low blood pressure and cyanosis
- D. Tachycardia and dizziness
Correct Answer: A
Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.
A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?
- A. Increased heart rate
- B. Persistent cough
- C. Constipation
- D. Sweating
Correct Answer: B
Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
- A. Eat a light snack before bedtime.
- B. Stay in bed at least 1 hr if unable to fall asleep.
- C. Take a 1 hr nap during the day.
- D. Perform exercises prior to bedtime.
Correct Answer: A
Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.
Which is the correct method for teaching a client to use a cane when they have left-leg weakness?
- A. Use the cane on the weaker side of the body
- B. Advance the cane and the strong leg together
- C. Maintain two points of support on the floor at all times
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: C
Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.
A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?
- A. Store enough water for 3 days
- B. Maintain communication with family
- C. Prepare only non-perishable food
- D. Prepare multiple escape routes
Correct Answer: A
Rationale: The correct answer is A: 'Store enough water for 3 days.' When preparing a home disaster supply kit, it is crucial to include enough water to last at least 3 days. This is because clean drinking water may not be readily available during a disaster situation. Choice B, 'Maintain communication with family,' is important for coordination but not directly related to preparing a supply kit. Choice C, 'Prepare only non-perishable food,' is also important but does not address the specific recommendation for water. Choice D, 'Prepare multiple escape routes,' is crucial for evacuation planning but does not pertain to the contents of a home disaster supply kit.