Nokea
After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises?
- A. Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange.
- B. Deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery.
- C. Deep breathing controls the rate of air flow to the remaining lobe so that it will not become hyperinflated.
- D. Deep breathing expands the alveoli and increases the lung surface available for ventilation.
Correct Answer: D
Rationale: Deep breathing expands alveoli, increasing lung surface for ventilation and preventing atelectasis post-thoracotomy. It does not elevate the diaphragm, increase blood flow, or control airflow to prevent hyperinflation.
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The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:
- A. Contact the surgeon to request an order for a narcotic for the pain.
- B. Maintain the client in a recumbent position.
- C. Place the client on nothing-by-mouth (NPO) status.
- D. Apply heat to the abdomen in the area of the pain.
Correct Answer: C
Rationale: The client with acute appendicitis should be placed on NPO status in preparation for surgery to prevent aspiration risk. Narcotics may mask symptoms, a recumbent position is not specific, and heat could worsen inflammation. CN: Physiological adaptation; CL: Synthesize
The nurse is preparing to transfuse platelets to a client. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Obtain the client's weight
- B. Ensure ABO type compatibility
- C. Infuse the platelets over 2 to 4 hours
- D. Verify completed consent for platelet transfusion
- E. Obtain pre-transfusion vital signs
Correct Answer: B,D,E
Rationale: Ensuring ABO compatibility prevents transfusion reactions, verifying consent ensures legal and ethical standards, and obtaining pre-transfusion vital signs establishes a baseline for monitoring. Platelet infusions are typically rapid (15–30 minutes), not 2–4 hours, and weight is not routinely required unless dosing is weight-based.
A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which of the following should be the primary focus of nursing care for this client?
- A. Providing activities of daily living on the time schedule that the client wishes.
- B. Offering foods that the client enjoys in order to increase the intake of calories.
- C. Decreasing cardiac demands by promoting rest.
- D. Listening to concerns about the hospitalization.
Correct Answer: C
Rationale: Thalassemia, a hemolytic anemia, causes increased cardiac workload due to chronic anemia and tissue hypoxia. Promoting rest is the primary focus to decrease cardiac demands and prevent complications like heart failure. While client preferences, nutrition, and emotional support are important, reducing cardiac strain is critical.
The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first:
- A. Administer Atropine 0.5 mg I.V. push.
- B. Auscultate for abnormal heart sounds.
- C. Prepare for transcutaneous pacing.
- D. Take the client's blood pressure.
Correct Answer: D
Rationale: A heart rate of 50 bpm may indicate bradycardia. Taking the blood pressure first assesses hemodynamic stability, guiding whether immediate intervention (e.g., atropine or pacing) is needed.
Which of the following terms describes the condition of a client with the disease in dosage to maintain adequate analgesia?
- A. Pseudoaddiction.
- B. Physical dependence.
- C. Psychological dependence.
- D. Drug tolerance.
Correct Answer: D
Rationale: Drug tolerance occurs when a client requires increased doses to maintain analgesia due to the body's adaptation to the medication.