Nokea
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress note
Correct Answer: A
Rationale: The correct answer is A: Client concerns. This is because the client themselves is the primary source of information about their own health and well-being. By directly listening to the client's concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but is secondary to the client's own input. Medical history (C) is important but may not always reflect the current situation. Progress notes (D) are valuable but are based on observations and interpretations by healthcare providers. Therefore, relying on the client's concerns ensures the most accurate and up-to-date information for the admission process.
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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 reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
- A. I'll use a humidifier beside my bed at night.
- B. I'll sleep better if I take a sleeping pill at night.
- C. I am going to try to lose about 50 pounds.
- D. I am going to have a glass of red wine before bedtime.
Correct Answer: C
Rationale: The correct answer is C: "I am going to try to lose about 50 pounds." This statement indicates the client's understanding of how weight loss can help reduce obstructive sleep apnea episodes in obese individuals. Excess weight can contribute to airway obstruction during sleep, leading to apneic episodes. Losing weight can alleviate this pressure on the airway, improving breathing during sleep.
A: Using a humidifier may help with dry air but does not directly address the underlying cause of obstructive sleep apnea.
B: Taking a sleeping pill can mask symptoms but does not address the root cause of the issue.
D: Consuming alcohol before bedtime can worsen sleep apnea symptoms as it relaxes the throat muscles, potentially increasing the risk of apneic episodes.
A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
- A. Lower the height of the solution container.
- B. Encourage the client to bear down.
- C. Allow the client to expel some fluid before continuing.
- D. Stop the enema and document that the client did not tolerate the procedure.
Correct Answer: A
Rationale: Correct Answer: A: Lower the height of the solution container.
Rationale: Lowering the height of the solution container will decrease the rate of flow, reducing the pressure and volume of the solution entering the client's colon. This can help alleviate the cramping sensation by slowing down the administration of the enema.
Summary of other choices:
B: Encouraging the client to bear down may increase intra-abdominal pressure, worsening the cramping sensation.
C: Allowing the client to expel some fluid before continuing may not address the root cause of the discomfort, which is the rapid influx of solution.
D: Stopping the enema and documenting that the client did not tolerate the procedure does not actively address the client's discomfort or provide immediate relief.
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A - Excessive laxative use can lead to constipation by causing dependency on laxatives. B - Ignoring the urge to defecate can disrupt normal bowel habits. C - Inadequate fluid intake can result in hard stools and difficulty passing them. Choices D and E are incorrect because increased fiber in the diet and increased activity are actually recommended interventions to alleviate constipation.
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.