Nokea
A nurse is performing chest physiotherapy for a client with a respiratory infection. Which of the following techniques should the nurse use to increase the velocity and turbulence of the air the client exhales?
- A. Postural drainage
- B. Nebulization
- C. Percussion
- D. Vibration
Correct Answer: D
Rationale: Vibration increases air turbulence and helps loosen secretions, facilitating expectoration.
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A nurse is rehearsing assertive communication approaches to decline leadership of a nursing department committee. Which of the following statements by the nurse demonstrates assertiveness?
- A. You know this is not the right time for me to do this.
- B. Everyone knows there are others who can chair this committee better than I could.
- C. Can you tell me why you chose me?
- D. I decline the opportunity at this time.
Correct Answer: D
Rationale: Assertive communication is direct and respectful, clearly stating a decision without being passive or aggressive.
A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?
- A. Unbroken skin with un-blancheable erythema
- B. Full-thickness tissue loss extending to underlying support structures
- C. A shallow, ruptured or intact skin blister without slough
- D. A deep crater without visible bone, tendon, or muscle
Correct Answer: D
Rationale: Stage 3 ulcers involve full-thickness skin loss with damage to subcutaneous tissue but without exposed bone or muscle.
A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
- A. Pain
- B. Hearing loss
- C. The client's culture
- D. Motor impairment
Correct Answer: A
Rationale: The correct answer is A. Pain can significantly impact a client's ability to concentrate and retain information during a teaching session. Pain can cause distress, affecting the client's focus and ability to engage in the learning process. Therefore, addressing pain as a priority before proceeding with discharge teaching is essential.
Hearing loss (B) can be accommodated with visual aids or written materials. Cultural considerations (C) can be integrated into the teaching plan. Motor impairment (D) can also be managed by providing alternative methods for learning. Other choices are not as critical as pain in hindering the learning process.
A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?
- A. Wear a mask when entering the client's room.
- B. Remove potted plants from the room.
- C. Allow the client to leave the room every 2 hr.
- D. Dedicate equipment and supplies for use with the client.
Correct Answer: D
Rationale: The correct answer is D: Dedicate equipment and supplies for use with the client. This is essential for preventing the spread of infection. By dedicating equipment to the client, the nurse reduces the risk of contaminating other clients. Choice A is incorrect because wearing a mask is not necessary for contact precautions unless respiratory droplets are a concern. Choice B is irrelevant to contact precautions. Choice C is incorrect as allowing the client to leave the room frequently can increase the risk of spreading infection.