Nokea
A nurse is reinforcing teaching with a client who has atelectasis. The nurse tells the client how to position herself to promote drainage of the apical lung segments. Which of the following statements by the client should the nurse identify as understanding of the teaching?
- A. I will sit up on the side of the bed with my legs dangling.
- B. I will turn on my left side with my legs elevated higher than my chest.
- C. I will position myself on my back with my head lower than my feet.
- D. I will lie on my abdomen with pillows under my stomach and chest.
Correct Answer: D
Rationale: Prone positioning with pillows under the chest promotes postural drainage of apical lung segments. Other positions are ineffective.
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A nurse is reviewing the plan of care for a client who has a respiratory infection. The nurse should plan to have the client lie on his stomach with pillows elevating his chest and stomach 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: C
Rationale: Prone positioning with elevation allows mucus drainage from posterior lung segments.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?
- A. Ask the client to perform a return demonstration of insulin injection.
- B. Review the action of insulin therapy.
- C. Explore the client's feelings about dietary modifications.
- D. Have a family member practice blood glucose monitoring using a glucometer.
Correct Answer: C
Rationale: The correct answer is C because exploring the client's feelings about dietary modifications focuses on the affective domain of learning, which involves emotions, attitudes, and values. By understanding the client's feelings, the nurse can address any concerns, fears, or resistance the client may have towards changing their diet. This approach helps to create a supportive and empathetic environment for the client to embrace necessary dietary changes.
Regarding the incorrect choices:
A: Asking the client to perform a return demonstration of insulin injection focuses on psychomotor skills, not affective learning.
B: Reviewing the action of insulin therapy focuses on cognitive learning, not affective learning.
D: Having a family member practice blood glucose monitoring is not directly related to addressing the client's emotional response to dietary modifications.
A nurse is supervising a newly licensed nurse who is female while she performs postmortem care on a male client who is Muslim. Which of the following actions by the newly licensed nurse should prompt the nurse to intervene?
- A. Leaves the client's dentures in his mouth
- B. Prepares to cleanse the client's body
- C. Disconnects the cardiac monitor from the client
- D. Removes soiled linens from the client
Correct Answer: B
Rationale: In Islamic practices, same-gender family members or religious personnel should perform body cleansing. A female nurse cleansing a male client would require intervention.
A nurse is assisting with the readmission of a client to the medical unit after a transfer to ICU following a suicide attempt using an overdose of medication. The client looks down at the floor and mumbles, 'Hello.' Which of the following responses should the nurse make?
- A. You have been transferred back to this unit. This is your new room.
- B. Hello. I see that in ICU you've been getting a light diet. How does your stomach feel now?
- C. I was upset when I found you had tried to kill yourself.
- D. Would you like to talk about what happened?
Correct Answer: D
Rationale: Encouraging open communication provides emotional support and helps the client process their feelings.
When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?
- A. Repeat the auscultation after asking the client to breathe deeply and cough.
- B. Instruct the client to limit fluid intake to less than 2,000 mL/day.
- C. Prepare to administer antibiotics.
- D. Initiate bedrest in semi-Fowler's position.
Correct Answer: A
Rationale: The correct answer is A. By asking the client to breathe deeply and cough, the nurse can assess if the crackles persist or change, helping to determine if they are related to secretions. This action can provide more information for a more accurate diagnosis and appropriate intervention. Option B is incorrect as limiting fluid intake is not directly related to addressing crackles. Option C is incorrect without further assessment or indication of infection. Option D is incorrect as bedrest in semi-Fowler's position is not the initial intervention for crackles.