Nokea
A nursing diagnosis of 'ineffective airway clearance related to pain' is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?
- A. Administer prescribed analgesic medication for incisional pain
- B. Encourage use of incentive spirometer every 2 hours while awake
- C. Offer an additional pillow to splint the incision while coughing
- D. Promote increased oral fluid intake
Correct Answer: A
Rationale: Pain control is the priority to enable effective coughing and airway clearance.
You may also like to solve these questions
The nurse is talking with the parent of an adolescent client who arrived at the emergency department after discovering that the client was involved in a motor vehicle collision. The parent asks about the clients condition. The client is unconscious and is currently receiving CPR. Which of the following responses would be appropriate for the nurse to make?
- A. I do not have any information about your child's condition, but you can see your child now.
- B. Your child is critically ill, and we are currently caring for your child's needs.
- C. The health care team is currently attempting to revive your child after your child's heart stopped.
- D. Only the health care provider is allowed to discuss your child's condition with you.
Correct Answer: C
Rationale: Honest, clear communication about the critical situation (CPR) is appropriate while maintaining sensitivity.
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.
Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
- A. Assist with plans for any clients discharged
- B. Provide basic hygiene care to all clients on the unit
- C. Assess a client after an acute myocardial infarction
- D. Gather the vital signs of all clients on the unit
Correct Answer: B
Rationale: Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.
The nurse is observing a certified nursing assistant move a client. Which action, if observed, indicates that the nursing assistant needs more instruction?
- A. The assistant stands with feet spread apart.
- B. The assistant bends from the waist.
- C. The assistant turns her whole body.
- D. The assistant keeps her back straight.
Correct Answer: B
Rationale: Bending from the waist strains the back, indicating improper technique. Wide stance, whole-body turning, and straight back are correct for safe client movement.
The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an understanding of the diet by stating
- A. I will increase sodium and fluids and restrict potassium.'
- B. I will increase potassium and sodium and restrict fluids.'
- C. I will increase sodium, potassium and fluids.'
- D. I will increase fluids and restrict sodium and potassium.'
Correct Answer: A
Rationale: The manifestations of Addison's disease due to mineralocorticoid deficiency, resulting from renal sodium wasting and potassium retention, include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.