Nokea
A nurse is caring for a client who has pneumonia. The nurse should place the client on his right side in Trendelenburg position 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 lower lobe
Correct Answer: D
Rationale: The Trendelenburg position promotes drainage of secretions from specific lung segments, improving oxygenation.
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A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?
- A. Use the left hand to cleanse the urinary meatus.
- B. Use the right hand to insert the catheter.
- C. Stand on the client's right side.
- D. Raise the bed to a comfortable working height.
Correct Answer: D
Rationale: The correct answer is D: Raise the bed to a comfortable working height. This is important to prevent strain on the nurse's back and ensure proper ergonomics during the procedure. Standing on the client's right side (Choice C) does not directly impact the procedure. Using the left hand to cleanse the urinary meatus (Choice A) could be challenging for a left-handed nurse and may not be as efficient. Using the right hand to insert the catheter (Choice B) could also be difficult for a left-handed nurse and may affect dexterity. Therefore, raising the bed to a comfortable working height is the most appropriate action to ensure the nurse's comfort and safety while performing the catheterization.
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?
- A. Put on sterile gloves.
- B. Assist the client to the left Sims' position.
- C. Hang the enema container 61 cm (24 in) above the anus.
- D. Insert the tubing about 15 cm (6 in) into the anus.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the left Sims' position. This position helps to facilitate the flow of the enema solution into the colon by allowing gravity to assist in the process. Placing the client in the left Sims' position helps to ensure proper administration and effectiveness of the enema.
A: Putting on sterile gloves is not necessary for administering a soapsuds enema.
C: Hanging the enema container 61 cm above the anus is not a standard practice for administering a soapsuds enema.
D: Inserting the tubing about 15 cm into the anus is too shallow and may not reach the desired area for the enema to be effective.
A nurse is assisting an older adult client plan an exercise regimen. Which of the following activities should the nurse encourage the client to avoid?
- A. Stretching
- B. Running
- C. Resistance training
- D. Aerobic exercises
Correct Answer: B
Rationale: The correct answer is B: Running. Older adults may have joint issues, reduced bone density, or balance problems which could be exacerbated by the high impact nature of running. Encouraging the client to avoid running can help prevent injuries. Stretching (A) helps maintain flexibility, resistance training (C) improves strength, and aerobic exercises (D) enhance cardiovascular health, all of which are beneficial for older adults.
A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?
- A. An NG tube to suction
- B. An indwelling urinary catheter to gravity drainage
- C. A chest tube to water-seal drainage
- D. A nephrostomy tube to a drainage bag
Correct Answer: A
Rationale: NG suction removes gastric contents, leading to loss of potassium and increased risk of hypokalemia.
A nurse is interviewing a female client who does not speak the same language as the nurse. The client's partner is translating what the nurse is saying to the client. Which of the following actions should the nurse take?
- A. Arrange to complete the data collection with only the client and a translator present.
- B. Ask the client's partner to translate questions and answers for the client.
- C. Record the partner's answers to the questions and complete the assessment.
- D. Ask the partner to allow the client to provide her own answers to the nurse's questions.
Correct Answer: A
Rationale: A professional translator ensures accuracy, maintains confidentiality, and reduces potential biases from family members.