Nokea
The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? Select all that apply.
- A. Avoiding being silhouetted against strong light.
- B. Not blocking out the person's view of the speaker's mouth.
- C. Facing the client when talking.
- D. Having bright light behind so the individual can see.
- E. Ensuring the client is familiar with the subject material before discussing.
- F. Talking to the client while doing other nursing procedures.
Correct Answer: A,B,C
Rationale: To facilitate lip-reading, the nurse should avoid strong backlighting, not block the view of the mouth, and face the client directly to ensure clear visibility of facial expressions and lips.
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The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would be most accurate?
- A. Surgery is usually required, although medical treatment is attempted first.'
- B. Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes.'
- C. Surgery is not performed for this type of hernia.'
- D. A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned.'
Correct Answer: B
Rationale: Most hiatal hernias are managed effectively with diet, medications, and lifestyle changes, making this the most accurate response.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
- A. Quality of breath sounds.
- B. Presence of bowel sounds.
- C. Occurence of chest pain.
- D. Amount of peripheral edema.
- E. Color of nail beds.
Correct Answer: A,C,E
Rationale: Breath sounds (A) indicate lung involvement. Chest pain (C) may signal pleurisy or complications. Nail bed color (E) reflects oxygenation. Bowel sounds and peripheral edema are less relevant to pneumonia assessment.
The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.
- A. Weigh weekly and report weight loss.
- B. When eating, sit and lean slightly forward.
- C. Have serum albumin level checked regularly.
- D. Administer enteral tube feedings as ordered.
- E. Manipulate the nasogastric tube daily.
Correct Answer: A,B,C,D
Rationale: To ensure adequate nutrition post-laryngectomy, the client should monitor weight, sit and lean forward to aid swallowing, check serum albumin for nutritional status, and use enteral feedings as ordered. Manipulating the tube is not recommended to avoid dislodgement.
During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for injury with compression over the xiphoid process?
- A. Lung.
- B. Liver.
- C. Stomach.
- D. Diaphragm.
Correct Answer: B
Rationale: Compressing the xiphoid process risks liver injury, as it lies directly beneath, potentially causing laceration or hemorrhage.