Nokea
A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.
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Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
- A. Increased urine output
- B. Adventitious breath sounds
- C. Decreased level of consciousness
- D. Dry crust on the incision line
- E. Oral temperature of 38.3°C (101°F)
Correct Answer: B,C,E
Rationale: Adventitious breath sounds suggest pneumonia, decreased consciousness may indicate sepsis, and fever is a systemic infection response. Increased urine output is not a sign, and dry crust is part of normal healing.
A nurse is caring for a client whose partner asks to speak with the nurse. The client's partner relates that she is concerned because her partner abuses alcohol and has difficulty maintaining employment. Which of the following responses should the nurse make?
- A. If I were you, I would contact a support group.
- B. I'm so sorry to hear about this.
- C. I suggest you talk with the hospital chaplain about your concern.
- D. What have you done in the past to cope with this issue?
Correct Answer: D
Rationale: Exploring the partner's past coping strategies encourages problem-solving and emotional support.
A nurse is caring for a client who is about to undergo exploratory surgery to remove a malignant tumor and to determine the extent of any metastasis. The client tells the nurse that she is not hopeful that she will recover and begins to cry. Which of the following responses should the nurse make?
- A. Reassure the client that the provider will use advanced medical knowledge to treat any further problems with her tumor.
- B. Sit quietly with the client and follow her cues.
- C. Suggest that the client discuss her fears with the provider.
- D. Gently change the subject to something more positive.
Correct Answer: B
Rationale: Providing silent support and allowing the client to express emotions promotes emotional well-being.
A nurse manager is talking with a nurse who was unable to sleep the previous night after participating in an unsuccessful client resuscitation. Which of the following responses should the nurse manager make?
- A. Tell me what your concerns are.'
- B. Maybe you should schedule an appointment with a psychiatrist.'
- C. It's hard at first, but you will get used to these things.'
- D. Don't worry. We all go through these feelings. They will pass.'
Correct Answer: A
Rationale: Encouraging the nurse to express concerns supports emotional well-being and prevents burnout.
A nurse is reinforcing dietary teaching with a client who tells the nurse she would like to reduce her solid fat intake and increase oil intake in her diet. Which of the following instructions should the nurse include in the teaching?
- A. Replace tub margarine with stick margarine.
- B. Use safflower oil instead of butter when baking.
- C. Consume 2% or whole milk.
- D. Choose ground beef that is at least 80% lean meat.
Correct Answer: B
Rationale: The correct answer is B: Use safflower oil instead of butter when baking. Safflower oil is a healthier option than butter as it is a plant-based oil that is lower in solid fats and higher in unsaturated fats. Solid fats like butter contain more saturated fats which can raise cholesterol levels. By substituting safflower oil for butter, the client can reduce solid fat intake and increase oil intake in a heart-healthy way.
Incorrect answers:
A: Replace tub margarine with stick margarine - Both tub and stick margarine are solid fats and should be limited in the diet to reduce solid fat intake.
C: Consume 2% or whole milk - Whole milk contains more solid fats compared to low-fat or skim milk, so this would not be a good choice to reduce solid fat intake.
D: Choose ground beef that is at least 80% lean meat - While lean meats are a good choice to reduce solid fat intake, ground beef still contains saturated fats.