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 caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
- A. Insert an IV catheter in the opposite extremity.
- B. Discontinue the existing IV infusion.
- C. Apply warm, moist compresses to the site.
- D. Elevate the extremity.
Correct Answer: B
Rationale: The correct action is to discontinue the existing IV infusion (Choice B) first. The redness, swelling, and warmth at the IV site indicate phlebitis, which is inflammation of the vein. Discontinuing the infusion is crucial to prevent further damage and infection. This step helps to stop the irritant (IV solution) from causing more harm. Inserting an IV catheter in the opposite extremity (Choice A) does not address the current issue and may lead to the same problem. Applying warm, moist compresses (Choice C) could potentially worsen the inflammation. Elevating the extremity (Choice D) may provide some relief, but it does not address the root cause. Therefore, discontinuing the existing IV infusion is the most appropriate immediate action to take in this situation.
A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?
- A. Allow the AP to deliver the food tray to the client.
- B. Call the dietary department and ask for a kosher meal tray.
- C. Replace the nonfat milk with apple juice.
- D. Explain to the client that he needs the protein in the milk and the beef.
Correct Answer: B
Rationale: Orthodox Jewish dietary laws prohibit consuming dairy and meat together, so a kosher meal should be requested.
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 caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
- A. Cracks in oral mucous membranes
- B. Poor skin turgor
- C. Tachycardia
- D. Excessive pulmonary secretions
Correct Answer: C
Rationale: Tachycardia can indicate oxygen toxicity. Other symptoms include confusion and restlessness. Pulmonary secretions are expected in pneumonia, not a sign of toxicity.
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.