Nokea
A nurse is planning care for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse implement to prevent respiratory complications?
- A. Encourage the client to ambulate twice daily.
- B. Encourage the client to deep breathe and cough every hour.
- C. Encourage the client to use an incentive spirometer every hour.
- D. Instruct the client to avoid coughing to prevent pain.
Correct Answer: C
Rationale: The correct answer is C. Encouraging the client to use an incentive spirometer every hour is crucial to prevent respiratory complications postoperatively. Incentive spirometry helps in lung expansion and prevents atelectasis, which is common after abdominal surgery. Choice A, encouraging ambulation, is important for preventing complications but does not directly address respiratory issues. Choice B, deep breathing and coughing every hour, is also beneficial but not as effective in preventing atelectasis as using an incentive spirometer. Choice D, instructing the client to avoid coughing, is incorrect as coughing helps clear secretions and prevent respiratory complications.
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A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
- A. Auscultate the apical pulse and count for 1 minute
- B. Place a sensor on the index finger
- C. Heat the skin prior to placing the probe
- D. Recheck after 10 minutes
Correct Answer: A
Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.
A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?
- A. Blow as hard as possible into the mouthpiece.
- B. Exhale quickly and forcefully after taking a deep breath.
- C. Inhale as deeply as possible and then blow into the mouthpiece.
- D. Take a deep breath and hold it for 5 seconds before exhaling.
Correct Answer: B
Rationale: The correct answer is B because the client should exhale quickly and forcefully into the peak flow meter after taking a deep breath to measure peak expiratory flow. Choice A is incorrect as blowing as hard as possible may not provide an accurate reading. Choice C is incorrect because inhaling deeply before blowing can affect the results. Choice D is incorrect as holding the breath before exhaling is not part of using a peak flow meter.
Which electrolyte imbalance is a common concern for patients on loop diuretics?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A, Hypokalemia. Loop diuretics can lead to potassium loss, resulting in hypokalemia. This imbalance is a common concern because potassium plays a vital role in various physiological functions, including maintaining proper heart function. Choices B, C, and D are incorrect because loop diuretics typically do not cause hyperkalemia, hyponatremia, or hypercalcemia.
Which electrolyte imbalance should be closely monitored in patients on diuretics?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Patients on diuretics are at risk of developing hypokalemia due to increased potassium excretion by the kidneys. Hypokalemia can lead to serious consequences such as cardiac arrhythmias. Hyponatremia (choice B) is an imbalance of sodium levels and is not typically associated with diuretic use. Hyperkalemia (choice C) is the opposite condition where potassium levels are elevated and is less common in patients on diuretics. Hypercalcemia (choice D) is an excess of calcium in the blood and is not directly related to diuretic use. Therefore, monitoring for hypokalemia is crucial in patients taking diuretics.
What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?
- A. Administer anticoagulants
- B. Encourage ambulation
- C. Apply compression stockings
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.