Nokea
The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client?
- A. Breathe in normally through your nose for 2 counts (while counting to yourself, one, two).
- B. Relax your neck and shoulder muscles.
- C. Pucker your lips as if you were going to whistle.
- D. Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four).
Correct Answer: B,A,C,D
Rationale: The correct order for pursed-lip breathing is: relax muscles (B), inhale through nose for 2 counts (A), pucker lips (C), exhale through pursed lips for 4 counts (D). This prolongs exhalation, reducing air trapping.
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What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
Which intervention is most appropriate for a client with impaired mobility due to a neurological condition?
- A. Encourage bed rest.
- B. Provide assistive devices.
- C. Limit physical therapy.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Providing assistive devices promotes safe mobility and independence for a client with impaired mobility.
A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. The nurse is preparing preoperative teaching. Which of the following should be included in the teaching plan to address potential changes in sexuality?
- A. Sexual intercourse will not be possible after surgery.
- B. Vaginal dryness may occur, and water-soluble lubricants can help.
- C. Menopausal symptoms will not occur if ovaries are preserved.
- D. Sexual desire will remain unchanged after surgery.
Correct Answer: B
Rationale: Vaginal dryness is a common side effect after hysterectomy due to changes in vaginal tissue and potential hormonal shifts, even if ovaries are preserved. Teaching about water-soluble lubricants helps the client prepare for and manage this change.
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be:
- A. Administer epinephrine
- B. Inform the physician
- C. Administer oxygen
- D. Inform the client that the procedure is almost over
Correct Answer: B
Rationale: Nausea, tingling, and dyspnea during an arteriogram suggest a possible allergic reaction to the contrast dye or other complications (e.g., vasovagal response). The nurse should immediately inform the physician to evaluate and manage the situation. Administering epinephrine or oxygen requires a physician's order, and reassuring the client is inappropriate until the issue is addressed.