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A nurse is reviewing the plan of care for a client who has a respiratory infection. The nurse should plan to have the client lie on his stomach with pillows elevating his chest and stomach 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: C
Rationale: Prone positioning with elevation allows mucus drainage from posterior lung segments.
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A nurse is caring for a client who has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?
- A. Obtain a soft mattress for the client's bed.
- B. Position soft pillows against the bottom of the feet.
- C. Use a footboard to maintain dorsiflexion of the feet.
- D. Cross the client's legs at the ankles.
Correct Answer: C
Rationale: The correct answer is C: Use a footboard to maintain dorsiflexion of the feet. This is important for preventing foot drop, a common issue with right-sided paralysis post-CVA. By maintaining dorsiflexion, the nurse helps prevent contractures and promotes proper alignment of the feet. A soft mattress (A) does not address the specific issue of foot drop. Positioning soft pillows against the bottom of the feet (B) may not provide adequate support and dorsiflexion. Crossing the client's legs at the ankles (D) is contraindicated as it can lead to pressure ulcers and further complications.
A nurse is caring for a client whose arterial blood gases include a pH of 7.30, an HCO3- of 18 mEq/L and a PaCO2 of 28 mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The correct answer is A: Metabolic acidosis. The pH is low (acidosis) and the HCO3- is also low, indicating a primary metabolic acidosis. The low PaCO2 (respiratory alkalosis compensation) further supports metabolic acidosis. Other choices are incorrect because B: Respiratory acidosis would have a high PaCO2, C: Metabolic alkalosis would have a high HCO3-, and D: Respiratory alkalosis would have a low PaCO2 with a high pH.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, dairy and meat products cannot be consumed together. The mixing of meat and dairy violates the dietary laws of Kashrut. Kosher chicken breast and boiled potatoes (choice D) are both permissible to eat together as they are both meat products. Carrot sticks and cottage cheese (choice B) are both dairy products and can be consumed together. Macaroni and cheese (choice C) is a dairy product and can be consumed alone or with other dairy products.
A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?
- A. Use a Snellen chart.
- B. Determine if the client's speech is hoarse.
- C. Present the client with mildly scented aromas.
- D. Ask the client to clench teeth.
Correct Answer: A
Rationale: The correct answer is A: Use a Snellen chart. Cranial nerve II, the optic nerve, is responsible for vision. By using a Snellen chart, the nurse can assess the client's visual acuity, which directly relates to the function of cranial nerve II. This method specifically targets the nerve in question and provides objective data on the client's vision.
Incorrect choices:
B: Determining if the client's speech is hoarse would assess cranial nerve X, the vagus nerve, responsible for speech and swallowing.
C: Presenting the client with scented aromas would assess cranial nerve I, the olfactory nerve, responsible for smell.
D: Asking the client to clench teeth would assess cranial nerve V, the trigeminal nerve, responsible for facial sensation and jaw movement.