Nokea
The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?
- A. Client's breath sounds are clear to auscultation bilaterally.
- B. Client exhibits a frequent productive cough.
- C. Client demonstrates proper use of an incentive spirometer.
- D. Client reports using the incentive spirometer every hour while awake.
Correct Answer: A
Rationale: Clear breath sounds indicate effective lung expansion, the primary goal of incentive spirometry, unlike cough, technique, or compliance.
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A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
- A. Implement seizure precautions.
- B. Begin straining all urine.
- C. Administer a PRN dose of a laxative.
- D. Initiate cardiac telemetry.
Correct Answer: B
Rationale: Straining urine checks for kidney stones, likely causing flank pain in hyperparathyroidism, prioritizing over other interventions.
A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?
- A. Report of bowel functioning since surgery.
- B. Heart rate and body weight.
- C. Number of any missed doses of medication.
- D. Daily caloric intake.
Correct Answer: B
Rationale: Heart rate and body weight assess thyroid replacement therapy effectiveness, reflecting metabolic rate changes.
A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?
- A. Assess the client's oxygen saturation level.
- B. Determine the client's current glucose level
- C. Give the client one-half cup of fruit juice.
- D. Give the client skim milk and crackers.
Correct Answer: B
Rationale: Checking glucose confirms hypoglycemia, indicated by symptoms, guiding appropriate treatment.
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?
- A. Place an indwelling urinary catheter and measure strict Intake and output.
- B. Initiate bilateral intermittent sequential pneumatic compression devices.
- C. Administer aspirin to prevent further det formation and platelet dumping.
- D. Obtain a focused history to determine recent bleeding and use of anticoagulants.
Correct Answer: D
Rationale: A focused history assesses for stroke risk factors like anticoagulant use, critical for managing neurological symptoms.