Nokea
A nurse is talking with a client who is beginning a program of moderate exercise. When the nurse reminds the client of the importance of doing warm-up exercises, the client asks why. Which of the following reasons should the nurse give?
- A. Stabilizes body temperature
- B. Enhances relaxation
- C. Reduces the risk of injury
- D. Readjusts to baseline function
Correct Answer: C
Rationale: The correct answer is C: Reduces the risk of injury. Warm-up exercises help increase blood flow to muscles, making them more flexible and responsive. This reduces the risk of muscle strains and injuries during exercise. Choice A is incorrect because while warm-up exercises may help regulate body temperature during exercise, that is not the primary reason for warm-ups. Choice B is incorrect as the primary purpose of warm-up exercises is not necessarily to enhance relaxation. Choice D is incorrect as warm-up exercises do not specifically readjust to baseline function; they prepare the body for exercise.
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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.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
- A. Cracks in oral mucous membranes
- B. Poor skin turgor
- C. Tachycardia
- D. Excessive pulmonary secretions
Correct Answer: C
Rationale: Tachycardia can indicate oxygen toxicity. Other symptoms include confusion and restlessness. Pulmonary secretions are expected in pneumonia, not a sign of toxicity.
A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.
A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?
- A. Determine the client's perception of his body image.
- B. Encourage the client to talk about his feelings regarding his body image.
- C. Discuss alternative coping strategies to relieve stress he feels about his body image.
- D. Assist the client to acknowledge he has a distorted body image.
Correct Answer: A
Rationale: Assessing the client's perception of their body image is the first step in understanding their emotional and psychological response.