Nokea
A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing?
- A. Inhale through the nose.
- B. Cough deeply from the lungs.
- C. Exhale through pursed lips.
- D. Splint the incisional site.
Correct Answer: D,A,C,B
Rationale: The correct order is: splint the incision (D) to reduce pain, inhale through the nose (A) to expand lungs, exhale through pursed lips (C) to control breathing, and cough deeply (B) to clear secretions.
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What is the nurse's best response to a client with Parkinson's experiencing dyskinesia?
- A. Increase medication dose.
- B. Teach relaxation techniques.
- C. Restrict all activity.
- D. Ignore the symptoms.
Correct Answer: B
Rationale: Teaching relaxation techniques can help manage dyskinesia, a side effect of Parkinson's medications.
The nurse is instructing a client who is at risk for peripheral vascular disease how to use knee-length elastic stockings (support hose). The teaching plan should include which of the following? Check all that apply.
- A. Apply the elastic stockings in the morning
- B. Remove the stockings if swelling occurs
- C. Apply the stockings while in bed
- D. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff
- E. Keep the stockings in place for 48 hours and reapply using a clean pair of stockings
Correct Answer: A,C
Rationale: Rationales: A) Applying elastic stockings in the morning before edema worsens helps promote venous return. C) Applying them while in bed (before standing) minimizes swelling and eases application. B) Removing stockings for swelling requires medical evaluation, not automatic removal. D) Rolling down to form a cuff creates pressure points, impairing circulation. E) Stockings should be removed daily for skin inspection and hygiene, not kept on for 48 hours.
The nurse should do which of the following to decrease a female client's anxiety about being placed in the lithotomy position for surgery?
- A. Explain in detail what will occur in the operating room.
- B. Determine what the client is concerned about.
- C. Pad the stirrups for comfort.
- D. Reassure the client that an all-female surgical team will be present.
Correct Answer: B
Rationale: Determining the client's specific concerns about the lithotomy position allows the nurse to address her anxiety directly, promoting trust and tailored reassurance.
Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
- A. Imbalanced nutrition: Less than body requirements.
- B. Ineffective health maintenance related to ineffective coping skills.
- C. Acute pain.
- D. Activity intolerance.
Correct Answer: A
Rationale: Nausea and vomiting from illness can lead to inadequate food intake, causing imbalanced nutrition, a priority due to the risk of hypoglycemia or ketoacidosis.
A nurse is caring for a client who is prescribed a medication with a narrow therapeutic index (NTI). Which action should the nurse take when administering this medication?
- A. Administer the medication as prescribed, ensuring strict adherence to the dosing schedule.
- B. Administer the medication concurrently with herbal supplements to augment its efficacy.
- C. Combine the medication with other medications to enhance its therapeutic effects.
- D. Administer the medication at a higher dose than prescribed to achieve faster results.
Correct Answer: A
Rationale: NTI medications require strict adherence to dosing to maintain therapeutic levels and avoid toxicity.