Nokea
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
- A. Splint or support the incision to promote maximal comfort.
- B. Inhale slowly through the nostrils; exhale through pursed lips.
- C. Hold the breath for about 5 seconds to expand the alveoli.
- D. Repeat this breathing method 5 to 10 times hourly.
- E. Close one nostril while inhaling.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (A), slow nasal inhalation with pursed-lip exhalation (B), holding the breath (C), and repeating 5-10 times hourly (D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
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Two days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg (Lortab 7.5/500). What should the nurse ask the client before administering the pain medication?
- A. œWhere is your pain located?'
- B. œHave you emptied your bladder?'
- C. œHow long has it been since your last dose?'
- D. œIs your pain better than before you had surgery?'
Correct Answer: C
Rationale: Asking about the time since the last dose ensures safe administration, preventing overdose or toxicity, as hydrocodone has a specific dosing interval.
Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply.
- A. A major risk factor for complications is obesity and central abdominal obesity.
- B. Supplemental insulin is mandatory for controlling the disease.
- C. Exercise increases insulin resistance.
- D. The primary nutritional source requiring monitoring in the diet is carbohydrates.
- E. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).
Correct Answer: A,D,E
Rationale: Obesity, especially central, is a major risk factor for complications. Carbohydrates require monitoring to manage blood glucose. Annual eye and foot exams are recommended. Insulin is not mandatory for type 2 diabetes, and exercise decreases insulin resistance.
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has:
- A. Enlarged, painless lymph nodes.
- B. Headache.
- C. Hyperplasia of the gums.
- D. Unintentional weight loss.
Correct Answer: A
Rationale: Early-stage CLL is often asymptomatic but may present with enlarged, painless lymph nodes due to lymphocyte accumulation. Headache, gum hyperplasia, and weight loss are not typical early findings.
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
- A. Arteries
- B. Aorta
- C. Carotid
- D. Veins
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.