Nokea
A nurse is caring for a client who has atelectasis. The nurse should instruct the client to lie on his back with a quarter turn elevating his right side and his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: Postural drainage in this position helps mobilize secretions from the lower lobes and prevent complications.
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A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.
A nurse is performing pulmonary hygiene for a client. The nurse should place the client on his right side with pillows elevating the left side of his chest to help 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 upper lobe
Correct Answer: C
Rationale: Elevation of specific lung areas helps drain mucus and prevent complications such as pneumonia or atelectasis.
A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
- A. Atelectasis
- B. Rales
- C. Rhonchi
- D. Pneumothorax
Correct Answer: A
Rationale: Atelectasis causes absent breath sounds in lung bases due to alveolar collapse.
A nurse is caring for a client who is unconscious. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member?
- A. To allow full extension of the hip and knee joints
- B. To prevent aspiration problems
- C. To promote lung expansion
- D. To prevent abdominal distention
Correct Answer: B
Rationale: The correct answer is B: To prevent aspiration problems. When a client is lying on their side, it helps prevent the pooling of secretions in the back of the throat, reducing the risk of aspiration. This is crucial for unconscious clients who may have difficulty protecting their airway.
Choice A is incorrect because lying on the side does not specifically relate to the extension of hip and knee joints. Choice C is incorrect as lying on the side does not directly promote lung expansion. Choice D is incorrect as lying on the side does not prevent abdominal distention.
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
- A. Provide support by holding the client's arm.
- B. Lean the client toward the wall.
- C. Lower the client to the floor.
- D. Maintain a narrow base of support.
Correct Answer: C
Rationale: The correct action for the nurse to take when a client begins to fall during ambulation is to lower the client to the floor (Choice C). This is the safest option to prevent further injury to the client. Lowering the client to the floor helps minimize the distance of the fall, reducing the risk of serious injury. Additionally, it allows for a controlled descent, ensuring the client lands safely. Providing support by holding the client's arm (Choice A) may not be enough to prevent a fall and could lead to both the nurse and the client getting injured. Leaning the client toward the wall (Choice B) may not provide adequate support and could still result in a fall. Maintaining a narrow base of support (Choice D) may not be effective in preventing a fall. The best course of action is to prioritize the safety of the client by lowering them to the floor in a controlled manner.