Nokea
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?
- A. Sit bolt upright in bed with the arms crossed over the chest.
- B. Lie on the side with the head of the bed at a 45-degree angle.
- C. Sit in a reclining chair tilted slightly back with the feet elevated.
- D. Sit on the edge of the bed with the arms leaning on an overbed table.
Correct Answer: D
Rationale: Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45-degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.
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The clinic nurse is providing instructions to a client in the third trimester of pregnancy regarding relief measures for heartburn. Which instruction should the nurse provide to the client?
- A. Sip on milk or hot tea.
- B. Use antacids that contain sodium.
- C. Eat fatty foods once a day in the morning only.
- D. Eat three large meals a day rather than small, frequent meals.
Correct Answer: A
Rationale: Sipping on milk or hot tea can soothe the gastrointestinal tract and relieve heartburn. Antacids containing sodium should be avoided to prevent edema. Fatty foods should be avoided entirely, and small, frequent meals are recommended to reduce heartburn in pregnancy.
A postpartum client recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. What action should the nurse encourage the client to avoid?
- A. Brushing her teeth
- B. Taking acetylsalicylic acid (aspirin)
- C. Walking long distances and climbing stairs
- D. All activities because bruising injuries can occur
Correct Answer: B
Rationale: Aspirin is an antiplatelet medication and can interact with the anticoagulant medication and increase the clotting time beyond therapeutic ranges, so avoiding aspirin is a priority. The client does not need to avoid brushing her teeth, but she should be instructed to use a soft toothbrush. Walking and climbing stairs are acceptable activities. Not all activities need to be avoided.
The nurse is providing education at a senior center. Which of the following measures will the nurse say is most effective in attaining normal blood pressure in a client with hypertension?
- A. eating red meat daily
- B. increasing potassium and calcium intake
- C. increasing fluid intake
- D. decreasing sodium intake
Correct Answer: D
Rationale: Decreasing sodium intake is the most effective dietary measure to manage hypertension, as sodium increases blood pressure. Red meat (A) may worsen it, potassium/calcium (B) is supportive but less impactful, and fluid intake (C) is not directly related.
The nurse has completed discharge teaching with the parents of a child diagnosed with glomerulonephritis. Which statement by the parents indicates that further teaching is necessary?
- A. We'll check our child's blood pressure every day.
- B. We'll test our child's urine for albumin every week.
- C. It'll be so good to have our child back in tap-dancing classes next week.
- D. We'll be sure that our child eats a lot of vegetables and does not add extra salt to food.
Correct Answer: C
Rationale: Tap dancing classes 1 week after discharge would be unrealistic and involve a too rapid increase in activity. Glomerulonephritis results in destruction, inflammation, and sclerosis of the glomeruli of the kidneys. After discharge, parents should allow the child to return to his or her normal routine and activities, with adequate periods allowed for rest. Taking daily blood pressure, testing urine weekly for albumin, and restricting extra sodium are appropriate home care measures.
The nurse is providing instructions to a client and family regarding home care after left-eye cataract removal. The nurse tells the client and family about assuming which position during the postoperative period?
- A. Sleep only on the left side.
- B. Sleep on the right side or the back.
- C. Bend below the waist as often as you are able.
- D. Lower the head between the knees three times a day.
Correct Answer: B
Rationale: After cataract surgery, the client is informed to sleep on the nonoperative side or his or her back. The client should not sleep on the operative side to prevent the development of edema. The client should also avoid bending below the level of the waist or lowering the head because these actions will increase intraocular pressure.