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A nurse is reviewing the medical record of a client who has pneumonia. The nurse should plan to have the client lie on his stomach in Trendelenburg position with pillows elevating the right side of his chest 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: D
Rationale: This positioning promotes drainage from the posterior right lower lobe by using gravity.
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A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?
- A. Assign another nurse to be responsible for obtaining capillary glucose levels.
- B. Verify that the newly licensed nurse attended the staff education class about capillary glucose levels.
- C. Repeat the capillary glucose levels.
- D. Recheck the next scheduled capillary glucose level immediately following the nurse's.
Correct Answer: C
Rationale: The correct answer is C: Repeat the capillary glucose levels. This action should be taken to confirm the accuracy of the initial results. By repeating the test, the charge nurse can determine if the inaccuracy was due to a procedural error or if there is an issue with the equipment. This step ensures that the client receives proper care based on accurate information.
Assigning another nurse (choice A) does not address the root cause of the inaccurate results. Verifying attendance at an education class (choice B) is not as immediate or relevant as repeating the test. Rechecking the next scheduled level (choice D) without verifying the accuracy of the initial result may lead to continued inaccuracies in care.
A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Poor skin turgor
- B. Bradycardia
- C. Hypotension
- D. Pale yellow urine
- E. Flat neck veins
Correct Answer: A,C,E
Rationale: Poor skin turgor, hypotension, and flat neck veins indicate dehydration due to fluid loss. Bradycardia is incorrect; tachycardia is expected. Pale yellow urine suggests adequate hydration.
A nurse is caring for a client who has type I diabetes mellitus and is not adhering to guidelines for therapy. Which of the following factors should the nurse consider as contributing to the nonadherence?
- A. Gender
- B. Culture
- C. Allergies
- D. Dexterity
- E. Motivation
Correct Answer: B,D,E
Rationale: Cultural beliefs, dexterity limitations, and motivation significantly impact adherence to diabetes management.
A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?
- A. Use medical aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply petroleum jelly to the peristomal skin.
Correct Answer: C
Rationale: Securing new tracheostomy ties before removing old ones prevents accidental displacement. Medical asepsis is insufficient; sterile technique is required.
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.