Nokea
A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
- A. Limit fluid intake to 1,000 mL per day.
- B. Administer oxygen at 2 L/min.
- C. Encourage use of incentive spirometry for 5 min every 2 hr.
- D. Teach the client a breathing exercise with a longer inhalation phase.
Correct Answer: D
Rationale: The correct answer is D. Teaching the client a breathing exercise with a longer inhalation phase helps improve lung capacity and strengthen respiratory muscles, which are essential for clients with emphysema. This intervention can help the client breathe more effectively and reduce shortness of breath. Option A is incorrect because limiting fluid intake is not a standard intervention for emphysema. Option B is incorrect as administering oxygen is not specific to improving lung function. Option C is incorrect as incentive spirometry is more effective if done for longer durations.
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A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage?
- A. Blood pressure 90/50 mm Hg
- B. Oxygen saturation 95%
- C. Heart rate 60/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 90/50 mm Hg. Dopamine is a vasopressor used to increase blood pressure in hypovolemic shock. A low blood pressure reading of 90/50 mm Hg indicates inadequate perfusion, warranting an increase in dopamine dosage to improve cardiac output. Oxygen saturation (B) and respiratory rate (D) are not direct indicators for adjusting dopamine dosage. A heart rate of 60/min (C) may be within normal limits depending on the client's condition.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.
A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I will limit my portions of meat to 8 ounces.
- B. I will increase my intake of canned vegetables.
- C. I will use canola oil when making salad dressing.
- D. I will drink whole milk with my cereal.
Correct Answer: C
Rationale: The correct answer is C: "I will use canola oil when making salad dressing." Canola oil is a healthier choice than other oils, as it is low in saturated fats and high in monounsaturated fats, which are beneficial for cardiovascular health. Using canola oil in salad dressing can help decrease the intake of unhealthy fats. Choice A is incorrect because limiting meat portions alone may not address overall dietary fat intake. Choice B is incorrect as canned vegetables may contain added sodium, which is not ideal for cardiovascular health. Choice D is incorrect as whole milk is high in saturated fats, not recommended for cardiovascular disease.
A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Surgical site
- C. Pain level
- D. Respiratory status
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (A) is important but can be affected by respiratory issues. Surgical site (B) assessment is important but not an immediate priority. Pain level (C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.'
- B. I rest in my recliner with my feet elevated for about an hour every afternoon.'
- C. I use my heating pad on a low setting to keep my feet warm.'
- D. I soak my feet in hot water before trimming my toenails.'
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease. Choice B may improve circulation, but it does not address foot care directly. Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease. Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.