Nokea
A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
- A. Prevent atelectasis.
- B. Reduce incisional pain.
- C. Improve circulation.
- D. Promote wound healing.
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.
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The nurse is planning a program about women's health and cancer prevention for a community health fair. The nurse should include information about? Select all that apply.
- A. Regular self-exams of the breast and vulva are important self-care activities.
- B. Cancer can be prevented by removing precancerous lesions of the vulva, cervix, or endometrium.
- C. Girls, age 11 to 12, should receive immunization for human papilloma virus (HPV) to prevent cervical cancer.
- D. Smoking cessation reduces the risk of cervical cancer.
- E. There is limited evidence that cancer in women is inherited.
Correct Answer: A,B,C
Rationale: Self-exams, removal of precancerous lesions, and HPV vaccination are key prevention strategies. Smoking cessation reduces lung cancer risk, not cervical. Some cancers have genetic links.
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply.
- A. Call his family to come in to visit with him.
- B. Notify his health care provider of the change.
- C. Place respiratory resuscitation equipment in the client's room.
- D. Check for advancing levels of paresthesia.
- E. Perform ankle pumps to increase circulation and relieve numbness.
Correct Answer: B,C,D
Rationale: Rapidly progressing numbness suggests a neurological condition like Guillain-Barré syndrome, requiring immediate provider notification (B), monitoring for respiratory involvement with resuscitation equipment (C), and ongoing assessment of paresthesia (D). Family visits and ankle pumps are not priorities.
The nurse is teaching unlicensed assistive personnel about caring for a client who is withdrawing from alcohol and street drugs. Which of the following communication techniques when observed by the nurse indicate the UAP has understood the instructions? The UAP talks to the client using:
- A. Matter-of-fact manner and short sentences.
- B. Cheerful tone of voice, using humor when appropriate.
- C. Loud voice and giving general comments.
- D. Clear explanations in a quiet voice.
Correct Answer: A
Rationale: A matter-of-fact manner with short sentences is effective for clients withdrawing from substances, as it minimizes confusion and agitation.
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions should be included?
- A. Avoid driving until seizures are controlled.
- B. Take baths instead of showers.
- C. Use a microwave instead of a stove.
- D. Sleep on a low bed with side rails.
Correct Answer: A, D
Rationale: Avoiding driving and using a low bed with rails prevent injury during seizures.
Which of the following is the most accurate method of determining the extent of a client's fluid loss?
- A. Measuring intake and output
- B. Assessing vital signs
- C. Weighing the client
- D. Assessing skin turgor
Correct Answer: C
Rationale: Daily weighing is the most accurate method to assess fluid loss, as 1 kg of weight loss corresponds to 1 liter of fluid loss. Intake/output, vital signs, and skin turgor are less precise.