Nokea
In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take deep breaths
- D. Take shallow breaths
Correct Answer: B
Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.
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A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid?
- A. Peanut butter and jelly sandwich and milk
- B. Corn beef and cabbage and boiled potatoes
- C. Oatmeal, whole-wheat toast, and milk
- D. Tuna on whole-wheat bread and iced tea
Correct Answer: B
Rationale: Gas-forming foods such as cabbage should be avoided.
The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: A pH of 7.47 (alkaline) with low PCO2 (28) indicates respiratory alkalosis, likely from hyperventilation due to brain injury. Normal HCO3 rules out metabolic causes.
The mother of a six-year-old with autistic disorder tells the nurse that her son has been much more difficult to care for since the birth of his sister. The best explanation for changes in the child's behavior is:
- A. The child did not want a sibling.
- B. The child was not adequately prepared for the baby's arrival.
- C. The child's daily routine has been upset by the birth of his sister.
- D. The child is just trying to get the parent's attention.
Correct Answer: C
Rationale: Children with autism often rely on structured routines, and disruptions, such as a new sibling, can lead to behavioral changes due to difficulty adapting to change.
The nurse is teaching a client with a history of atrial fibrillation about medication adherence. The nurse should tell the client to:
- A. Take anticoagulants as prescribed
- B. Skip doses if feeling better
- C. Increase caffeine intake
- D. Avoid hydration
Correct Answer: A
Rationale: Anticoagulants reduce stroke risk in atrial fibrillation, so adherence is critical.
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.