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A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
- A. Increase the client's oral fluid intake.
- B. Initiate humidification therapy.
- C. Encourage the client to cough and deep breathe.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: The correct action is to raise the head of the bed (Choice D) first. This helps improve ventilation and oxygenation by optimizing lung expansion and reducing the work of breathing. Elevating the head of the bed promotes better oxygen exchange in pneumonia patients. Increasing oral fluid intake (Choice A) may be beneficial but not the priority in this scenario. Humidification therapy (Choice B) may help with secretions but does not directly address the oxygenation concern. Encouraging cough and deep breathing (Choice C) is important for lung hygiene but should come after ensuring adequate oxygenation.
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A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.
A nurse is reinforcing teaching with a client about crutch walking using the swing-through gait. Which of the following statements should the nurse include?
- A. Look down at your feet before moving the crutches.
- B. Place one crutch forward with the opposite foot and then place the second crutch forward with the other foot.
- C. Move both crutches forward, then lift and move your body past the crutches.
- D. Bear your weight against the underarm crutch pads.
Correct Answer: C
Rationale: The correct answer is C: Move both crutches forward, then lift and move your body past the crutches. This statement correctly describes the swing-through gait technique where both crutches are moved forward simultaneously followed by the client lifting and moving their body past the crutches. This technique helps maintain balance and stability during crutch walking. Looking down at your feet before moving the crutches (Choice A) is incorrect as it can cause the client to lose their balance. Placing one crutch forward with the opposite foot and then the second crutch forward with the other foot (Choice B) is the incorrect description of the swing-to gait technique. Bearing weight against the underarm crutch pads (Choice D) is incorrect as it can cause discomfort and potential nerve damage.
A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?
- A. Dilated pupils
- B. Dysrhythmias
- C. Diarrhea
- D. Gastric ulcer
Correct Answer: B
Rationale: The correct answer is B: Dysrhythmias. Straining while defecating can increase intra-abdominal pressure, leading to a vagal response that triggers dysrhythmias in susceptible individuals. This can be particularly dangerous for older adults with underlying heart conditions. Dilated pupils (choice A) are not directly related to straining during defecation. Diarrhea (choice C) is the opposite of constipation and is not a common consequence of straining. Gastric ulcers (choice D) are typically caused by factors such as H. pylori infection or NSAID use, not straining during defecation.
A nurse is caring for a client who has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?
- A. Obtain a soft mattress for the client's bed.
- B. Position soft pillows against the bottom of the feet.
- C. Use a footboard to maintain dorsiflexion of the feet.
- D. Cross the client's legs at the ankles.
Correct Answer: C
Rationale: The correct answer is C: Use a footboard to maintain dorsiflexion of the feet. This is important for preventing foot drop, a common issue with right-sided paralysis post-CVA. By maintaining dorsiflexion, the nurse helps prevent contractures and promotes proper alignment of the feet. A soft mattress (A) does not address the specific issue of foot drop. Positioning soft pillows against the bottom of the feet (B) may not provide adequate support and dorsiflexion. Crossing the client's legs at the ankles (D) is contraindicated as it can lead to pressure ulcers and further complications.
A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.