Nokea
A nurse is reviewing the medical record for a client who has pneumonia. The nurse should plan to have the client lie on his back with his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: C
Rationale: Trendelenburg position assists in draining secretions from the anterior lower lung segments.
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A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following actions should the nurse take?
- A. Irrigate the eye daily with 0.9% sodium chloride irrigation solution.
- B. Dim the lights in the room.
- C. Instill ophthalmic ointment into the lower lid.
- D. Keep the client off her left side.
Correct Answer: C
Rationale: The correct answer is C: Instill ophthalmic ointment into the lower lid. This action helps prevent corneal abrasions by keeping the eye moist and lubricated. Irrigating the eye with saline solution (choice A) may not provide adequate protection. Dimming the lights (choice B) doesn't directly address eye protection. Keeping the client off her left side (choice D) is unrelated to eye care.
A client who has a femur fracture states, 'I can't stay in this bed any longer. I need to get home so I can take care of my family.' The nurse responds by saying, 'You have talked about your family. Can you tell me more about your specific concerns?' Which of the following therapeutic communication techniques is the nurse using?
- A. Summarizing
- B. Empathizing
- C. Focusing
- D. Clarifying
Correct Answer: C
Rationale: Focusing helps the client explore concerns in more detail, allowing for appropriate support and planning.
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing the supplies, which of the following steps should the nurse perform next?
- A. Cleanse the meatus.
- B. Don sterile gloves.
- C. Cleanse the labia.
- D. Lubricate the catheter.
Correct Answer: B
Rationale: The correct next step is to don sterile gloves (choice B). This is essential to maintain aseptic technique and prevent infection during catheter insertion. Sterile gloves create a barrier between the nurse's hands and the client's urinary tract, reducing the risk of introducing pathogens. Cleansing the meatus (choice A) or labia (choice C) should come after donning sterile gloves to prevent contamination. Lubricating the catheter (choice D) should be done just before insertion to facilitate a smooth and comfortable procedure.
A nurse is assisting with speaking in front of a group of nurses about new guidelines to prevent pressure ulcers. Which of the following actions by the nurse demonstrates confidence?
- A. The nurse stands tall before talking.
- B. The nurse paces back and forth while making the speech.
- C. The nurse looks down at her notes for the duration of the talk.
- D. The nurse taps her foot repeatedly during the speech.
Correct Answer: A
Rationale: Standing tall with good posture conveys confidence and authority while speaking.
A nurse is caring for a client who has pneumonia. The nurse should place the client on his right side in Trendelenburg position to help mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: The Trendelenburg position promotes drainage of secretions from specific lung segments, improving oxygenation.