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A nurse is instructing a client about postural drainage. The nurse should have the client lie on his stomach with his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: D
Rationale: Prone Trendelenburg position aids in secretion clearance from posterior lung segments.
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A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
- A. Wait 30 min and return to measure the client's oral temperature.
- B. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.
- C. Document the inability to obtain an accurate reading of the client's oral temperature.
- D. Proceed to measure the client's oral temperature.
Correct Answer: A
Rationale: The correct answer is A: Wait 30 min and return to measure the client's oral temperature. When a client consumes ice chips, it can significantly lower their oral temperature, leading to an inaccurate reading. Waiting for 30 minutes allows the ice chips to melt and the oral temperature to stabilize. Providing warm water (choice B) may not be effective in raising the oral temperature quickly enough for an accurate reading. Documenting the inability to obtain an accurate reading (choice C) is not proactive in ensuring accurate assessment. Proceeding to measure the client's oral temperature (choice D) without allowing time for the ice chips to melt will likely result in an inaccurate reading.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop the coordination and balance needed to ride a tricycle around the age of 3. This activity helps improve gross motor skills and coordination. Jumping rope (A) requires more advanced motor skills and coordination. Printing letters and numbers (C) involves fine motor skills that develop later. Using scissors to cut out a picture (D) also requires more advanced fine motor skills and hand-eye coordination.
A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?
- A. When the client has the urge to defecate
- B. Every 2 hr while the patient is awake
- C. Immediately before meals
- D. After the client feels abdominal cramping
Correct Answer: A
Rationale: The correct answer is A: When the client has the urge to defecate. This is crucial for a successful bowel training program because it helps the client establish a regular bowel routine and strengthens the mind-body connection for recognizing the urge to defecate. Taking the client to the bathroom when they feel the urge also promotes independence and empowers the client to listen to their body's signals.
Choice B (Every 2 hr while the patient is awake) is incorrect because it does not align with the principles of bowel training, which focuses on responding to the body's natural signals. Choice C (Immediately before meals) is incorrect as the timing is not based on the client's physiological cues. Choice D (After the client feels abdominal cramping) is incorrect because waiting for abdominal cramping can lead to discomfort and is not proactive in managing bowel movements.
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, dairy and meat products cannot be consumed together. The mixing of meat and dairy violates the dietary laws of Kashrut. Kosher chicken breast and boiled potatoes (choice D) are both permissible to eat together as they are both meat products. Carrot sticks and cottage cheese (choice B) are both dairy products and can be consumed together. Macaroni and cheese (choice C) is a dairy product and can be consumed alone or with other dairy products.
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.