Nokea
A nurse is performing chest physiotherapy for a client with a respiratory infection. Which of the following techniques should the nurse use to increase the velocity and turbulence of the air the client exhales?
- A. Postural drainage
- B. Nebulization
- C. Percussion
- D. Vibration
Correct Answer: D
Rationale: Vibration increases air turbulence and helps loosen secretions, facilitating expectoration.
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A nurse manager is talking with a nurse who was unable to sleep the previous night after participating in an unsuccessful client resuscitation. Which of the following responses should the nurse manager make?
- A. Tell me what your concerns are.'
- B. Maybe you should schedule an appointment with a psychiatrist.'
- C. It's hard at first, but you will get used to these things.'
- D. Don't worry. We all go through these feelings. They will pass.'
Correct Answer: A
Rationale: Encouraging the nurse to express concerns supports emotional well-being and prevents burnout.
A nurse is collecting data from the daughter of an older adult client. Which of the following statements by the daughter is a priority to the nurse?
- A. My mother is unable to bathe herself.'
- B. We sit outside every afternoon.'
- C. We buy the prescriptions we can afford.'
- D. My mother seems depressed.'
Correct Answer: C
Rationale: Financial constraints affecting medication adherence pose an immediate health risk and require intervention.
A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.
A nurse is caring for a client who has dyspnea, crackles, and 3+ bilateral pitting pedal edema. Which of the following serum sodium levels should the nurse identify as an indication of fluid volume excess?
- A. 116 mEq/L
- B. 136 mEq/L
- C. 142 mEq/L
- D. 167 mEq/L
Correct Answer: A
Rationale: The correct answer is A (116 mEq/L). A low serum sodium level indicates dilutional hyponatremia, which can occur in fluid volume excess. In this case, the client's symptoms of dyspnea, crackles, and pedal edema point towards fluid overload. A serum sodium level of 116 mEq/L reflects dilution due to excess fluid in the body, indicating fluid volume excess. Choices B, C, and D have normal to high sodium levels, which do not correlate with fluid volume excess. Therefore, A is the most appropriate choice based on the client's clinical presentation.
A nurse is reinforcing teaching with a client on how to use meditation and progressive relaxation techniques to manage stress. Which of the following physiologic outcomes should the nurse instruct the client to expect?
- A. Arousal reduction
- B. Decreased blood pressure
- C. Decreased heart rate
- D. Increased oxygen consumption
- E. Increased respiratory rate
Correct Answer: A,B,C
Rationale: Meditation and relaxation techniques reduce physiological stress responses, leading to lower blood pressure, heart rate, and arousal.