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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 checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate assessment of the client's heart rate. It allows for any irregularities or fluctuations in the pulse to be detected.
Choice B is incorrect as using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, should be used to listen to the apical pulsations for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the client's skin can create artifact noise and interfere with accurate auscultation.
A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D, respiratory alkalosis. Hyperventilation causes excessive loss of carbon dioxide, leading to respiratory alkalosis. This is evidenced by lightheadedness, paresthesias, blurred vision, and confusion due to decreased carbon dioxide levels in the blood. Metabolic acidosis (A) is characterized by low pH and bicarbonate levels, not seen in this scenario. Metabolic alkalosis (B) is due to excess bicarbonate, which is not present in hyperventilation. Respiratory acidosis (C) is caused by retention of carbon dioxide, opposite of what is seen in hyperventilation.
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 caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?
- A. Autonomy vs. Shame and Doubt
- B. Generativity vs. Stagnation
- C. Identity vs. Role Diffusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: The correct answer is D: Integrity vs. Despair. According to Erikson's psychosocial development theory, acceptance of death occurs during the final stage of life, which is Integrity vs. Despair. In this stage, individuals reflect on their lives and come to terms with their mortality, finding a sense of fulfillment and wisdom. Option A (Autonomy vs. Shame and Doubt) focuses on developing a sense of independence in early childhood. Option B (Generativity vs. Stagnation) pertains to middle adulthood and concerns contributing to society and future generations. Option C (Identity vs. Role Diffusion) relates to adolescence and the formation of a sense of self. These stages do not specifically address acceptance of death.
A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?
- A. Assist the guest to the floor and begin mouth-to-mouth resuscitation.
- B. Observe the guest before taking further action.
- C. Perform the Heimlich maneuver on the guest.
- D. Slap the guest on the back several times.
Correct Answer: C
Rationale: The correct answer is C: Perform the Heimlich maneuver on the guest. This is the appropriate action for a choking individual who is unable to speak or breathe. The Heimlich maneuver helps dislodge the obstruction from the airway by applying abdominal thrusts. It is crucial to act quickly in such situations to prevent further complications like loss of consciousness or asphyxiation.
Choice A is incorrect as mouth-to-mouth resuscitation is not appropriate for a choking victim. Choice B is incorrect as observing without taking immediate action can be dangerous if the individual's airway is completely blocked. Choice D is incorrect as slapping the back may not effectively dislodge the obstruction. It is essential to prioritize the Heimlich maneuver to clear the airway and restore breathing.