Nokea
The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?
- A. Respiratory rate of 16 breaths per minute
- B. Blood pressure of 120/80 mm Hg
- C. Temperature of 99.5 degrees Fahrenheit
- D. Heart rate of 80 beats per minute
Correct Answer: C
Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.
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A client who is pregnant and has hyperemesis gravidarum is being taught about nutrition at home by a nurse. Which of the following statements indicate that the client understands the teachings?
- A. I will drink water with my meals.
- B. I will eat every 6 hours throughout the day.
- C. I will eat crackers before I get out of bed in the morning.
- D. I will limit my protein intake.
Correct Answer: C
Rationale: The correct answer is C. Eating crackers before getting out of bed can help manage nausea associated with hyperemesis gravidarum. Choice A is incorrect because drinking water with meals may exacerbate nausea. Choice B is incorrect as eating every 6 hours may not be frequent enough to combat nausea and vomiting. Choice D is incorrect because protein intake should not be limited during pregnancy, especially in cases of hyperemesis gravidarum.
A client wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase?
- A. Blueberries
- B. Soybean oil
- C. Citrus fruits
- D. Green tea
Correct Answer: B
Rationale: The correct answer is B: Soybean oil. Soybean oil is a good source of omega-3 fatty acids, which are beneficial for heart health. Blueberries (choice A), citrus fruits (choice C), and green tea (choice D) are not significant sources of omega-3 fatty acids. Blueberries are rich in antioxidants, citrus fruits provide vitamin C, and green tea contains polyphenols, but they do not offer a substantial amount of omega-3 fatty acids compared to soybean oil.
Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?
- A. Assessing the client's level of consciousness
- B. Monitoring the client's oxygen saturation
- C. Checking the client's gag reflex before eating or drinking
- D. Monitoring the client's intake and output
Correct Answer: C
Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.
A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keeping conversations short is the most appropriate intervention to promote comfort for a client with pneumonia. Pneumonia can be physically exhausting, and limiting the length of conversations helps conserve the client's energy. Encouraging visits from family and friends (Choice B) may be emotionally supportive but might not directly promote comfort in the context of conserving energy during recovery. Increasing oral fluid intake (Choice A) is important for hydration but may not directly address the client's comfort. Monitoring vital signs frequently (Choice D) is essential for assessing the client's condition but does not directly promote comfort.
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. Relaxation and sleep
- B. Deep breathing and coughing
- C. Incisional healing
- D. Range of motion exercises
Correct Answer: B
Rationale: Effective pain management encourages deep breathing and coughing, which are crucial for preventing complications after thoracic surgery. These actions help prevent respiratory complications such as pneumonia and atelectasis, promote lung expansion, and improve oxygenation. While relaxation and sleep are important for recovery, the priority after a thoracotomy and lobectomy is to prevent respiratory issues. Incisional healing is important but not the primary focus immediately post-surgery. Range of motion exercises are not directly related to promoting recovery after thoracic surgery.