Nokea
A nurse is reinforcing teaching with a client who is scheduled for abdominal surgery about coughing and deep breathing. Which of the following statements should the nurse make?
- A. Inhale through your mouth when deep breathing.
- B. Cough and deep breath every 4 hours.
- C. Lie supine to cough and deep breath.
- D. Splint your incision with a pillow when coughing.
Correct Answer: D
Rationale: Splinting the incision with a pillow reduces pain and supports the surgical site during coughing, enhancing effectiveness post-surgery.
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A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications?
- A. Postoperative cognitive dysfunction
- B. Dementia
- C. Alzheimer's disease
- D. Postoperative delirium
Correct Answer: D
Rationale: Postoperative delirium causes acute, temporary confusion post-surgery, common in older adults.
A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?
- A. Constipation
- B. Memory loss
- C. Brittle hair
- D. Bleeding gums
Correct Answer: A
Rationale: Insufficient fiber causes constipation by reducing bowel movement frequency.
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
- A. Withhold the feeding if the residual volume is 150 mL
- B. Flush the tube with 30 mL of sterile water before the feeding
- C. Cleanse the top of the can of formula with an alcohol wipe
- D. Keep the formula cold until instillation
Correct Answer: B
Rationale: Flushing with 30 mL of sterile water ensures tube patency and prevents clogging before feeding.
A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include?
- A. Inflammation
- B. Remodeling phase
- C. Maturation
- D. Proliferation
Correct Answer: A
Rationale: Inflammation is the first phase of wound healing, initiating hemostasis and infection prevention.
A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
- A. The nurse administers the feeding through a syringe barrel by gravity.
- B. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
- C. The nurse allows the client to rest in a supine position during feeding.
- D. The nurse irrigates the NG tube with tap water after feeding.
Correct Answer: C
Rationale: Supine position during feeding increases aspiration risk; semi-Fowler's is recommended.