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A nurse is caring for a client who has a respiratory infection. When the client asks how the position the nurse put him in can help, the nurse should explain that lying on his left side in Trendelenburg position helps mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Postural drainage uses gravity to mobilize mucus from different lung segments, aiding in secretion clearance.
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A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Bell's palsy is characterized by muscle distortion due to facial nerve paralysis, leading to asymmetry in facial expressions (A). Pain behind the ear may occur due to inflammation or compression of the facial nerve (B). Impaired taste can result from altered function of the chorda tympani nerve, affecting taste sensation on the anterior two-thirds of the tongue (E). Choices C, D, F, G are incorrect as hearing loss is not a typical feature of Bell's palsy (C), facial twitching is more characteristic of conditions like hemifacial spasm (D), and there are no specific findings associated with F and G in Bell's palsy.
A nurse is caring for a client who is to undergo surgery the next day. The client tells the nurse, 'I'm afraid of what's going to happen.' Which of the following responses should the nurse make?
- A. Assure the client that the surgery is safe and complications are rare.
- B. Encourage the client to discuss her fears further.
- C. Inform the client that she has an excellent provider and has nothing to worry about.
- D. Explain to the client that anxiety can prolong hospitalization.
Correct Answer: B
Rationale: Encouraging the client to talk about their fears provides emotional support and can reduce anxiety.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?
- A. Encourage the client to ambulate more often.
- B. Encourage coughing and deep breathing.
- C. Encourage the client to drink more fluids.
- D. Encourage regular use of the incentive spirometer.
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to drink more fluids. Increased fluid intake helps to thin respiratory secretions, making it easier for the client to cough them up and clear the airways. This action promotes effective airway clearance and reduces the risk of complications such as pneumonia worsening. Encouraging ambulation (A) is beneficial for overall lung health but does not directly address thinning of respiratory secretions. While coughing and deep breathing (B) are important for clearing secretions, increasing fluids is more effective in thinning them. Using the incentive spirometer (D) helps with lung expansion but does not directly thin secretions.
A nurse is reinforcing teaching with a client who has a new diagnosis of heart failure. Which of the following tools should the nurse use when speaking with the client? (Select all that apply.)
- A. Materials should be culturally diverse.
- B. Information must be accurate and current.
- C. Materials should be written at the eighth-grade level.
- D. Materials should be written in the client's spoken language.
- E. Materials should be distributed to the client in advance.
Correct Answer: A,B,C,D
Rationale: The correct tools for teaching a client with heart failure should include: A) Culturally diverse materials to ensure relevance and understanding across different backgrounds; B) Accurate and current information to provide the client with up-to-date knowledge for managing their condition effectively; C) Materials written at an eighth-grade level to ensure clarity and ease of comprehension; D) Materials in the client's spoken language to facilitate understanding and communication. These tools are essential for effective patient education in heart failure management. Other choices are incorrect as they may not address the client's specific needs or may hinder their understanding of the information.
A nurse is collecting data from a client who reports persistent vomiting, dizziness, palpitations, and numbness and tingling in his fingers and toes and around his mouth. The nurse notes the client's respirations are slow and shallow. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic alkalosis. The client's symptoms of vomiting, dizziness, palpitations, numbness and tingling, along with slow and shallow respirations, indicate a loss of hydrogen ions (H⁺) and chloride ions (Cl⁻) due to prolonged vomiting, leading to metabolic alkalosis. Vomiting causes a loss of stomach acid (HCl), leading to an increase in blood pH. Respiratory acidosis (C) results from inadequate ventilation, causing CO₂ retention and increased carbonic acid in the blood. Respiratory alkalosis (D) is characterized by hyperventilation and decreased CO₂ levels. Metabolic acidosis (A) involves a decrease in blood pH due to an excess of metabolic acids or a loss of bicarbonate ions.