A nurse is performing pulmonary hygiene for a client. The nurse should place the client on his right side with pillows elevating the left side of his chest to help mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right upper lobe
Correct Answer: C
Rationale: Elevation of specific lung areas helps drain mucus and prevent complications such as pneumonia or atelectasis.
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A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first?
- A. Disconnect the tube from the wall suction.
- B. Perform hand hygiene and don gloves.
- C. Observe the amount and color of drainage.
- D. Verify provider order to discontinue the tube.
Correct Answer: D
Rationale: The correct answer is D: Verify provider order to discontinue the tube. This is the first step the nurse should take before removing the NG tube to ensure that the removal is in line with the provider's instructions. Removing the tube without a valid order can lead to complications. Disconnecting the tube from wall suction (A) should be done after verifying the order. Performing hand hygiene and donning gloves (B) is important but can be done after verifying the order. Observing the amount and color of drainage (C) is important but should come after verifying the order.
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 caring for a client who has dyspnea, crackles, and 3+ bilateral pitting pedal edema. Which of the following serum sodium levels should the nurse identify as an indication of fluid volume excess?
- A. 116 mEq/L
- B. 136 mEq/L
- C. 142 mEq/L
- D. 167 mEq/L
Correct Answer: A
Rationale: The correct answer is A (116 mEq/L). A low serum sodium level indicates dilutional hyponatremia, which can occur in fluid volume excess. In this case, the client's symptoms of dyspnea, crackles, and pedal edema point towards fluid overload. A serum sodium level of 116 mEq/L reflects dilution due to excess fluid in the body, indicating fluid volume excess. Choices B, C, and D have normal to high sodium levels, which do not correlate with fluid volume excess. Therefore, A is the most appropriate choice based on the client's clinical presentation.
A nurse is reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.
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