Nokea
The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.
You may also like to solve these questions
A client with a history of a hiatal hernia is being taught about dietary management. The nurse should encourage the client to:
- A. Eat large meals
- B. Avoid caffeine
- C. Lie down after meals
- D. Eat high-fat foods
Correct Answer: B
Rationale: Caffeine relaxes the lower esophageal sphincter, worsening hiatal hernia symptoms. Small meals, avoiding lying down post-meals, and low-fat foods are recommended.
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Politely tells the client, 'Keep your hands off'
- B. Ignores the remarks and hopes he will not try it again
- C. Confronts the remarks but attempts not to reject the client
- D. Leaves the room in order to compose herself
Correct Answer: C
Rationale: By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship.
The client is admitted to the ER with multiple rib fractures on the right. The nurse's assessment reveals that an area over the right clavicle is puffy and that there is a "crackling" noise with palpation. The nurse should further assess the client for which of the following problems?
- A. Flail chest
- B. Subcutaneous emphysema
- C. Infiltrated subclavian IV
- D. Pneumothorax
Correct Answer: B
Rationale: Puffy skin and crackling (crepitus) over the clavicle suggest subcutaneous emphysema, where air escapes into tissues, often with rib fractures. Flail chest (A) involves paradoxical chest movement, infiltrated IV (C) is unrelated, and pneumothorax (D) causes absent breath sounds.
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
- A. The nurse should use universal precautions when obtaining blood samples.
- B. Total bed rest should be maintained until the client is asymptomatic.
- C. The client should be instructed to maintain a low semi-Fowler position when eating meals.
- D. The nurse should administer an alcohol backrub at bedtime.
Correct Answer: A
Rationale: Universal precautions are critical due to the bloodborne nature of hepatitis C. The other options are not appropriate for hepatitis C care.
A client with a history of chronic lymphocytic leukemia is admitted with complaints of lymphadenopathy. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Lymphadenopathy in chronic lymphocytic leukemia increases infection risk, so monitoring for infection is the priority.