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After collecting the sputum specimen from the client, which nursing action is most appropriate?
- A. Administer oxygen
- B. Provide mouth care
- C. Offer nourishment
- D. Encourage ambulation
Correct Answer: B
Rationale: Providing mouth care after sputum collection improves client comfort and removes residual sputum from the mouth.
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If the client identifies that lunches often include the following foods, which meal is the most nutritious?
- A. Tossed salad, rice, and iced tea
- B. Apple sandwich on whole wheat bread and coffee
- C. Meatless chili with beans, corn bread, and milk
- D. Chicken soup, gelatin, and sweetened lemonade
Correct Answer: C
Rationale: Meatless chili with beans, corn bread, and milk provides protein, carbohydrates, and calcium, making it the most balanced and nutritious option.
Which action is most appropriate for the nurse to take before the bronchoscopy?
- A. Keep the client NPO for at least 6 hours.
- B. Have the client cough several times.
- C. Ensure that the client gets adequate sleep.
- D. Scrub the client's upper chest with an antiseptic.
Correct Answer: A
Rationale: Keeping the client NPO for at least 6 hours prevents aspiration during bronchoscopy, which involves sedation.
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client?
- A. Confusion and lethargy.
- B. High fever and chills.
- C. Frothy sputum and edema.
- D. Bradypnea and jugular vein distention.
Correct Answer: A
Rationale: Elderly pneumonia patients often present with confusion/lethargy (A) due to hypoxia. Fever/chills (B) are less common in the elderly, frothy sputum/edema (C) suggest heart failure, and bradypnea/JVD (D) are unrelated.
After the client receives the weekly injection, which nursing instruction is essential?
- A. Take a couple of aspirin before leaving.
- B. Wait at least 30 minutes before leaving.
- C. Make sure someone else drives the car.
- D. Avoid getting the injection site wet.
Correct Answer: B
Rationale: Clients must wait at least 30 minutes after an allergy injection to monitor for potential allergic reactions, such as anaphylaxis.
If the client has normal cardiovascular and renal function, what is an appropriate goal for oral intake in the next 24-hour period?
- A. 500 mL
- B. 1,000 mL
- C. 1,500 mL
- D. 3,000 mL
Correct Answer: D
Rationale: For a client with fever and influenza, 3,000 mL of fluid intake helps prevent dehydration, assuming normal cardiovascular and renal function.