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A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct Answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.
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A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?
- A. Encourage the client to increase fluid intake.
- B. Suction the client every 2 hours.
- C. Perform chest physiotherapy every 8 hours.
- D. Administer oxygen via nasal cannula.
Correct Answer: A
Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.
How should a healthcare professional manage a patient with respiratory distress?
- A. Administer bronchodilators
- B. Administer oxygen
- C. Check oxygen saturation
- D. Reposition the patient
Correct Answer: B
Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.
A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect?
- A. Increased urine output
- B. Increased serum sodium
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: C
Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.
A client with hypertension is receiving discharge teaching from a nurse on managing blood pressure at home. Which of the following instructions should the nurse include?
- A. Take medication at bedtime.
- B. Check blood pressure once a week.
- C. Use a blood pressure cuff that fits snugly around the arm.
- D. Stop taking medication once blood pressure is within the normal range.
Correct Answer: C
Rationale: The correct answer is C: 'Use a blood pressure cuff that fits snugly around the arm.' Using a properly fitting cuff is essential for accurate blood pressure measurements. Choice A is incorrect because the timing of medication administration should be individualized and not specified in the question. Choice B is incorrect as checking blood pressure once a week may not provide sufficient monitoring for a client with hypertension. Choice D is incorrect because stopping medication abruptly once blood pressure is normal can lead to rebound hypertension and complications.
A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?
- A. Instruct the client to use an alcohol-free mouthwash.
- B. Apply heat packs to the radiation site.
- C. Provide a diet low in carbohydrates.
- D. Avoid exposure to direct sunlight during treatment.
Correct Answer: D
Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.