Nokea
The nurse is assisting a client with deep breathing and coughing exercises following abdominal surgery. What instruction is most appropriate for the nurse to give the client?
- A. Hold your breath for several seconds and then breathe out forcefully.
- B. Splint your incision while taking in deep breaths and coughing.
- C. Take deep breaths when you are moving in bed.
- D. Deep breathing exercises should be done when you are out of bed.
Correct Answer: B
Rationale: Splinting the incision reduces pain and supports effective deep breathing and coughing, preventing postoperative complications.
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The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Shortness of breath and crackles.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about glimepiride (Amaryl). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication before breakfast.
- B. I should report sweating to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping glimepiride when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: pre-breakfast dosing maximizes efficacy, sweating indicates hypoglycemia, and alcohol increases hypoglycemia risk.
Procrastination, noncompliance, and intentional inefficiency are characteristics of the client with:
- A. Avoidant personality disorder
- B. Antisocial personality disorder
- C. Compulsive personality disorder
- D. Passive aggressive personality disorder
Correct Answer: D
Rationale: Passive aggressive personality disorder is characterized by indirect resistance, such as procrastination and intentional inefficiency.
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication. Options A, B, and D are normal.
A client had a radical mastectomy for cancer in her right breast.
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
- A. Position the client on her left side with her right arm protected in a sling.
- B. Position the client on her right side with her right arm elevated.
- C. Position the client in semi-Fowler's position with her right arm elevated.
- D. Position the client in the prone position with her right arm elevated.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate