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An 8-year-old client is returned to the recovery room after a bronchoscopy.
- A. How should the nurse position an 8-year-old client after a bronchoscopy?
- B. In semi-Fowler’s position.
- C. Prone, with the head turned to the side.
- D. With the head of the bed elevated 45° and the neck extended.
- E. Supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position promotes lung expansion and reduces the risk of airway obstruction from edema or secretions post-bronchoscopy. Prone positioning limits respiratory assessment, neck extension risks airway obstruction, and supine does not optimize breathing.
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A 20-year-old primipara attends a class for women who plan to breastfeed. To prepare for breastfeeding, the nurse should encourage the women to
- A. apply moisturizer to their breasts every day after bathing.
- B. expose their breasts to air every day for 20 minutes.
- C. wash their breasts with water and rub with a towel every day.
- D. massage their breasts to increase circulation twice daily.
Correct Answer: C
Rationale: prepares nipples for stretching action of sucking during breastfeeding, soap avoided to prevent drying
The nurse is caring for a client with a history of congestive heart failure.
- A. Which instruction is most important for a client with congestive heart failure?
- B. Weigh yourself daily at the same time.
- C. Take extra diuretics if you feel short of breath.
- D. Eat a high-sodium diet to maintain electrolytes.
- E. Avoid exercise to prevent cardiac strain.
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.
In caring for an elderly client with a depressed affect, which of the following nursing actions would be MOST appropriate to help the client to complete activities of daily living?
- A. Medicate the client before the activities begin.
- B. Develop a written schedule of activities, allowing extra time.
- C. Assist the client with grooming activities so it doesn't take as long.
- D. Provide frequent forceful direction to keep the client focused.
Correct Answer: B
Rationale: written schedule with built-in extra time will allow client to understand what is expected and will allow him to participate at a slower pace
A patient complains of pain after an appendectomy. After administering an analgesic, the nurse should take which of the following actions?
- A. Elevate the head of the bed 30-45°.
- B. Place a pillow behind the patient's knees.
- C. Elevate the knee gatch on the bed 30°.
- D. Lie the client supine with a small pillow under the head.
Correct Answer: A
Rationale: would reduce stress on suture line and provide for comfort
A family member of a client who has sustained an electrical burn states, 'I don't understand why he has been here a week. The burn does not look that bad.' Which of the following responses by the nurse is BEST?
- A. Electrical burns are more prone to infection.
- B. Electrical burns are always much worse than they look on the outside.
- C. Cardiac monitoring is important because electrical burns affect cardiac function.
- D. Electrical burns can be deceptive because underlying tissue is also damaged.
Correct Answer: D
Rationale: electrical burn injuries are typically more injurious to underlying tissue such as nerve and vascular tissue, which require complex and timely treatment