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A nurse is reinforcing teaching with a client who is scheduled for a sigmoidoscopy. Which of the following instructions should the nurse include?
- A. Fast for 12 hours before the procedure.
- B. Use an enema the evening before.
- C. Expect general anesthesia.
- D. Avoid drinking fluids after the procedure.
Correct Answer: B
Rationale: Using an enema the evening before a sigmoidoscopy clears the lower colon for a clear view during the procedure.
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A nurse is caring for a client who has a new diagnosis of Sjögren's syndrome. Which of the following findings should the nurse expect?
- A. Dry eyes
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Dry eyes are a hallmark symptom of Sjögren's syndrome due to decreased tear production from autoimmune gland dysfunction.
A nurse is reinforcing teaching with a client who has a new prescription for a clonidine patch. Which of the following instructions should the nurse include?
- A. Apply the patch to the same site each week.
- B. Remove the patch after 12 hours.
- C. Apply the patch to the upper arm.
- D. Leave the patch on for 48 hours.
Correct Answer: C
Rationale: Applying the clonidine patch to the upper arm (or other recommended sites) ensures effective delivery of the medication.
A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper CPAP use?
- A. There is one finger width between the strap on the mask and the client's face.
- B. The therapeutic dose of albuterol is being inhaled.
- C. The mask fits loosely so air can escape from underneath.
- D. The mask is secured over the client's mouth and the client's nose is uncovered.
Correct Answer: A
Rationale: There is one finger width between the strap on the mask and the client's face is correct. A properly fitted CPAP mask should have a snug fit, with a space of about one finger width between the strap and the face to ensure adequate seal and comfort. A mask that is too tight can cause discomfort, while a loose mask may not provide the necessary pressure to treat sleep apnea.
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
- A. You should use patterned-paced breathing when changing positions.
- B. You should change positions as little as possible.
- C. You can splint the incision with a pillow when changing positions.
- D. You can apply counterpressure to your back with each position change.
Correct Answer: C
Rationale: Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.
A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?
- A. Pain in the right upper abdomen
- B. Discomfort with urination
- C. Pain radiating to the jaw
- D. Increased abdominal discomfort prior to meals
Correct Answer: A
Rationale: Pain in the right upper abdomen is correct. Acute cholecystitis is the inflammation of the gallbladder, typically caused by gallstones blocking bile flow. This condition leads to severe right upper quadrant (RUQ) pain, often triggered by fatty meals and sometimes accompanied by nausea, vomiting, and fever.