Nokea
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
- A. Request that the provider prescribe a stool softener.
- B. Promote active range-of-motion activities.
- C. Add fluid and fiber to the diet.
- D. Avoid gas-producing foods.
Correct Answer: C
Rationale: The correct answer is C: Add fluid and fiber to the diet. Increasing fluid intake helps soften the stool, making it easier to pass. Fiber adds bulk to the stool, promoting regular bowel movements. This is a non-invasive and effective intervention for constipation in older adults. Requesting a stool softener (A) may be considered if dietary interventions are ineffective. Promoting active range-of-motion activities (B) may help prevent constipation but is not the first-line intervention. Avoiding gas-producing foods (D) is not directly related to treating constipation.
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A nurse is reviewing the medical record of a client who has pneumonia. The nurse should plan to have the client lie on his stomach in Trendelenburg position with pillows elevating the right side of his chest 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: This positioning promotes drainage from the posterior right lower lobe by using gravity.
A nurse is reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
A nurse is caring for a client whose belongings were lost in a hurricane. The client says, 'What's the use in starting over? It will probably happen again.' Which of the following responses should the nurse make?
- A. I am sure everything will work out.'
- B. It appears you are feeling hopeless.'
- C. It is probably not as bad as you think.'
- D. I would not worry about what can't be changed.'
Correct Answer: B
Rationale: Acknowledging feelings of hopelessness is therapeutic and encourages the client to express emotions.
A nurse is caring for a client who has a hearing loss in her left ear. Which of the following nursing actions should the nurse take?
- A. Over articulate words to improve client understanding.
- B. Change voice volume during each sentence.
- C. Minimize background noise to decrease distractions.
- D. Sit in a chair to one side of the client.
Correct Answer: C
Rationale: Minimizing background noise enhances communication for clients with hearing loss.
A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated 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: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.