Nokea
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
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The nurse recognizes which of the following is considered an internal disaster?
- A. Water failure in the facility.
- B. Overcrowding in the emergency department.
- C. Mass shooting at a nearby concert.
- D. Shortage of opioid analgesia in the surgical department.
Correct Answer: A
Rationale: Water failure is an internal disaster as it originates within the facility. A mass shooting is external, while overcrowding and shortages are operational issues.
The nurse is caring for a client with right-sided weakness. When transferring the client from the bed to a wheelchair, which action should the nurse perform?
- A. Place the wheelchair as close to the bed as possible on the client's unaffected side
- B. Place the wheelchair as close to the bed as possible on the client's affected side.
- C. Remove any nonskid slippers from the client's feet
- D. Gently pull on the client's arm to assist them to the side of the bed
Correct Answer: A
Rationale: Placing the wheelchair on the unaffected side (left) allows the client to pivot on their stronger side. Affected-side placement, removing slippers, or pulling the arm risk injury or falls.
The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply.
- A. Empty their bladder before bed.
- B. Take more naps throughout the day.
- C. Eat a high amount of calories before bed.
- D. Plan vigorous exercise earlier in the day.
- E. Use multiple nightlights in the bedroom.
Correct Answer: A,D
Rationale: Emptying the bladder and exercising early promote sleep. Naps, high-calorie meals, and multiple lights disrupt sleep hygiene.
The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply.
- A. The client reports feeling nauseated.
- B. The client's lower extremities are swollen.
- C. The client expresses nervousness about test results.
- D. The client reports that their leg is itching.
- E. The client rates pain at a 6 on a scale of 1 to 10.
- F. The client vomits twice after eating dinner.
Correct Answer: A,C,D,E
Rationale: Subjective data are client-reported, like nausea, nervousness, itching, and pain rating. Swelling and vomiting are objective, observed by the nurse.
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply.
- A. Place a small pillow between the client's knees.
- B. Places the client's arms at their side.
- C. Fanfold a drawsheet along the backside of the client.
- D. Instruct the client to laterally flex the neck during the turn.
- E. Roll the client as one unit in a smooth, continuous motion.
Correct Answer: A,B,C,E
Rationale: Pillow placement, arms at sides, drawsheet use, and rolling as a unit maintain spinal alignment. Neck flexion risks injury during log rolling.