Nokea
The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
- A. Increase his nasal O2 to 6 L/min
- B. Place him in a lateral Sims' position
- C. Encourage pursed-lip breathing
- D. Have him breathe into a paper bag
Correct Answer: C
Rationale: Pursed-lip breathing helps blow off CO2 and keep air passages open, reducing shortness of breath. Increasing O2 too high may remove the breathing stimulus, and the other options are not appropriate.
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A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 2, ab 1
- B. Gravida 5, para 3, ab 1
- C. Gravida 5, para 4, ab 0
- D. Gravida 4, para 3, ab 0
Correct Answer: B
Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. I understand your concern and will assist you with a referral.'
- B. Try not to worry because you will just upset your child.'
- C. Just ignore the behavior and it should disappear by age 8.'
- D. This is appropriate behavior for a preschooler and should not be a concern.'
Correct Answer: D
Rationale: This is normal for a preschooler, and a referral is not appropriate. Telling a parent not to worry is unhelpful. This response does not address the mother's concern. This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. This behavior is normal development for a preschooler.
The nurse is caring for a client with a history of Crohn’s disease. Which dietary recommendation is most appropriate?
- A. High-fiber diet
- B. Low-residue diet
- C. High-fat diet
- D. Low-protein diet
Correct Answer: B
Rationale: A low-residue diet reduces bowel irritation in Crohn’s disease, minimizing symptoms like diarrhea. High-fiber diets exacerbate symptoms, and high-fat or low-protein diets are not indicated.
A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:
- A. Create a sense of well-being and self-worth
- B. Help him overcome respiratory infections
- C. Establish an effective, habitual breathing pattern
- D. Promote normal growth and development
Correct Answer: C
Rationale: Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern.
Before administering eardrops to a toddler,the nurse should recognize that it is essential to consider which of the following?
- A. Age
- B. Weight
- C. Developmental level
- D. Ability to understand
Correct Answer: C
Rationale: The toddler’s developmental level affects cooperation and ability to follow instructions during eardrop administration. Age is a factor but less specific and weight or understanding are secondary to developmental considerations.