Nokea
A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
- A. Atelectasis
- B. Rales
- C. Rhonchi
- D. Pneumothorax
Correct Answer: A
Rationale: Atelectasis causes absent breath sounds in lung bases due to alveolar collapse.
You may also like to solve these questions
A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?
- A. Bacteria
- B. Parasites
- C. Blood
- D. Fat
Correct Answer: C
Rationale: The correct answer is C: Blood. A stool guaiac test is used to detect the presence of occult (hidden) blood in the feces, which may indicate gastrointestinal bleeding. This test helps in diagnosing various gastrointestinal conditions such as ulcers, polyps, or colorectal cancer. Detecting blood in the stool is crucial for early diagnosis and intervention. Choices A, B, and D are incorrect as stool guaiac test specifically looks for blood, not bacteria, parasites, or fat in the feces. Blood in the stool is a significant finding that requires further investigation, making it the appropriate response in this scenario.
A nurse is talking with a client who is beginning a program of moderate exercise. When the nurse reminds the client of the importance of doing warm-up exercises, the client asks why. Which of the following reasons should the nurse give?
- A. Stabilizes body temperature
- B. Enhances relaxation
- C. Reduces the risk of injury
- D. Readjusts to baseline function
Correct Answer: C
Rationale: The correct answer is C: Reduces the risk of injury. Warm-up exercises help increase blood flow to muscles, making them more flexible and responsive. This reduces the risk of muscle strains and injuries during exercise. Choice A is incorrect because while warm-up exercises may help regulate body temperature during exercise, that is not the primary reason for warm-ups. Choice B is incorrect as the primary purpose of warm-up exercises is not necessarily to enhance relaxation. Choice D is incorrect as warm-up exercises do not specifically readjust to baseline function; they prepare the body for exercise.
A nurse is planning to reinforce teaching with a client who has a low health literacy level. Which of the following methods should the nurse use?
- A. Provide four important points.
- B. Explain information using passive voice.
- C. Use third person.
- D. Have two information sessions.
Correct Answer: A
Rationale: The correct answer is A because providing four important points can help simplify and organize information for a client with low health literacy. Breaking down information into key points can enhance understanding and retention. Choice B using passive voice may confuse the client. Choice C using third person may create distance and hinder engagement. Choice D having two information sessions could overwhelm the client. In summary, choice A is the most effective method for reinforcing teaching with a client with low health literacy.
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C. Listening attentively when the client talks about the past is essential in helping the older adult cope with feelings of grief. By actively listening, the nurse validates the client's feelings and provides a supportive environment for the client to express and process their emotions. This approach shows empathy and understanding, which can help the client feel heard and respected.
Choice A is incorrect because simply stating that it is a common problem does not address the client's individual feelings and may diminish the significance of their grief. Choice B is incorrect as it suggests avoidance rather than addressing the client's emotions directly. Choice D is incorrect as comparing the client's experience to that of younger clients may not be relevant or helpful.
When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?
- A. Repeat the auscultation after asking the client to breathe deeply and cough.
- B. Instruct the client to limit fluid intake to less than 2,000 mL/day.
- C. Prepare to administer antibiotics.
- D. Initiate bedrest in semi-Fowler's position.
Correct Answer: A
Rationale: The correct answer is A. By asking the client to breathe deeply and cough, the nurse can assess if the crackles persist or change, helping to determine if they are related to secretions. This action can provide more information for a more accurate diagnosis and appropriate intervention. Option B is incorrect as limiting fluid intake is not directly related to addressing crackles. Option C is incorrect without further assessment or indication of infection. Option D is incorrect as bedrest in semi-Fowler's position is not the initial intervention for crackles.