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The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient's return demonstration, the patient exhales using pursed lips. What should the nurse do next?
- A. Advise the patient that the procedure is being performed correctly.
- B. Tell the patient to take several shallow breaths before the next exhalation.
- C. Instruct the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times.
- D. Position the patient in the semi-Fowler's position and apply oxygen.
Correct Answer: C
Rationale: Instructing the patient to inhale deeply and exhale forcefully corrects the improper pursed-lip technique, ensuring effective huff coughing to clear mucus.
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The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?
- A. Lumbar puncture.
- B. Skull radiography.
- C. Magnetic resonance imaging (MRI).
- D. Computerized tomography (CT) scan.
Correct Answer: A
Rationale: A lumbar puncture is the primary diagnostic procedure for bacterial meningitis, allowing analysis of cerebrospinal fluid for bacterial presence and characteristics.
A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute. Which intervention is most important for the nurse to implement?
- A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Administer intravenous fluid bolus as prescribed by the healthcare provider.
Correct Answer: A
Rationale: Applying oxygen addresses potential hypoxia or respiratory distress indicated by the elevated vital signs.
An obese client with emphysema, who smokes at least a pack of cigarettes daily, is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan?
- A. Guidelines for oxygen use.
- B. Approaches to conserve energy.
- C. Strategies for smoking cessation.
- D. Methods for weight loss.
Correct Answer: A
Rationale: Correct oxygen use guidelines are critical to ensure safety and efficacy in managing emphysema.
An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?
- A. Elevate the head of the bed.
- B. Initiate a bowel prep protocol for surgery.
- C. Educate the patient on increasing dietary fiber.
- D. Maintain the patient's NPO status.
Correct Answer: D
Rationale: Maintaining NPO status rests the bowel, promoting healing during acute diverticulitis.
A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?
- A. Encourage continued maintenance of the walking routine.
- B. Advise less weight-bearing to prevent joint destruction.
- C. Recommend walking indoors for improved stability and safety.
- D. Suggest a calcium supplement along with continued walking.
Correct Answer: A
Rationale: Encouraging the client to continue their walking routine supports their desire to stay active and promotes muscle strength, flexibility, and overall well-being, which are beneficial for managing osteoarthritis.