Nokea
The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included?
- A. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.
- B. Lie flat on the back, splint the thorax, take two deep breaths, and cough.
- C. Take several rapid, shallow breaths and then cough forcefully.
- D. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.
Correct Answer: A
Rationale: Effective coughing in COPD involves a deep abdominal breath, bending forward, and coughing 3–4 times on exhalation to clear secretions. Other methods are less effective or impractical.
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Postoperative nursing care for a client after an appendectomy should include which of the following?
- A. Administering sitz baths four times a day.
- B. Noting the first bowel movement after surgery.
- C. Limiting the client's activity to bathroom privileges.
- D. Measuring abdominal girth every 2 hours.
Correct Answer: B
Rationale: Noting the first bowel movement after an appendectomy is important to confirm the return of bowel function. Sitz baths, limited activity, or measuring girth are not standard post-appendectomy care. CN: Physiological adaptation; CL: Synthesize
The following scenario applies to the next 1 items
The nurse has received prescriptions for a newborn infant in the postpartum unit.
Item 1 of 1
Orders
1958:
• phytonadione 1 mg intramuscular (IM) x 1 dose
• erythromycin ophthalmic ointment 0.5% apply from unit dose (1 cm) to both eyes
The nurse administers the prescribed medications.
The nurse should administer the phytonadione using ............ The nurse will inject the medication.............................It would be appropriate for the nurse to ...................... The nurse understands that the purpose of administering newborn erythromycin ophthalmic ointment is ............................. The nurse should apply this ointment to the ......................... Once the ointment is administered, the nurse should ..........................
- A. ¾-in, 25-gauge needle.
- B. into the middle third of the anterolateral aspect of the thigh.
- C. aspirate before injecting the medication.
- D. massage the area to promote medication absorption.
- E. prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.
- F. lower conjunctival sac.
- G. wipe the ointment from the outer eye after one minute.
Correct Answer: A,B,D,E,F
Rationale: Phytonadione is administered with a 25-gauge, ¾-in needle in the vastus lateralis; erythromycin prevents ophthalmia neonatorum and is applied to the lower conjunctival sac without wiping.
The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first?
- A. Call the Post Anesthesia Care Unit (PACU).
- B. Call the primary care physician.
- C. Call the respiratory therapist.
- D. Call the Rapid Response Team.
Correct Answer: D
Rationale: Rapid, shallow respirations, tachycardia, hypotension, and deteriorating consciousness suggest shock or respiratory distress. Calling the Rapid Response Team ensures immediate intervention.
The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of the following nursing interventions is most appropriate for this client in the postoperative period?
- A. Maintain the client in a semi-Fowler's position.
- B. Assist the client with warm sitz baths.
- C. Administer 30 mL of milk of magnesia to stimulate colostomy activity.
- D. Remove the ostomy pouch as needed so the stoma can be assessed.
Correct Answer: B
Rationale: Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary to be available to change the ostomy pouch to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage. CN: Physiological adaptation; CL: Synthesize
Which of the following characteristics displayed by the wife of a 36-year-old man with pancreatic cancer suggests that she may be at risk for negative bereavement outcomes?
- A. She is preparing for her husband's death.
- B. Her high socioeconomic status.
- C. Her strong family support.
- D. She blames herself for her husband's cancer.
Correct Answer: D
Rationale: Self-blame indicates unresolved guilt, which is a risk factor for negative bereavement outcomes, as it can complicate the grieving process.