Nokea
The nurse is teaching the client about deep-breathing techniques. Which of the following client statements indicates the need for additional education?
- A. œI will use my incentive spirometer every hour while I'm awake.'
- B. œI should place my hands lightly over my lower ribs and upper abdomen.'
- C. œI should get into a comfortable position before doing my breathing exercises.'
- D. œI should take four deep breaths and then cough deeply from the lungs.'
Correct Answer: D
Rationale: Taking four deep breaths before coughing is incorrect, as the client should perform deep breaths and cough in a sequence, typically 2-3 breaths followed by a cough, to prevent atelectasis effectively.
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Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
- A. Quality of breath sounds.
- B. Presence of bowel sounds.
- C. Occurence of chest pain.
- D. Amount of peripheral edema.
- E. Color of nail beds.
Correct Answer: A,C,E
Rationale: Breath sounds (A) indicate lung involvement. Chest pain (C) may signal pleurisy or complications. Nail bed color (E) reflects oxygenation. Bowel sounds and peripheral edema are less relevant to pneumonia assessment.
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:
- A. Adds dried fruit to cereal and baked goods.
- B. Cooks tomato-based foods in iron pots.
- C. Drinks coffee or tea with meals.
- D. Adds vitamin C to all meals.
Correct Answer: C
Rationale: Drinking coffee or tea with meals inhibits iron absorption due to tannins, which bind to iron and reduce its bioavailability. This indicates a lack of understanding of nutritional counseling for anemia, as the client should avoid these beverages during meals. Adding dried fruit (iron source), cooking in iron pots (increases iron content), and consuming vitamin C (enhances iron absorption) are appropriate strategies.
A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply.
- A. Do not allow blood pressures or blood draws in the affected arm.
- B. Avoid application of sunscreen on the left arm.
- C. Use an electric razor for shaving.
- D. Immobilize the left arm.
- E. Elevate the left arm.
- F. Perform hand pump exercises.
Correct Answer: A,C,E,F
Rationale: Preventing trauma (A, C), elevating the arm (E), and performing exercises (F) reduce lymphedema risk and promote lymphatic drainage. Sunscreen (B) is safe, and immobilization (D) is not recommended.
Which of the following is the most common initial manifestation of acute renal failure?
- A. Dysuria.
- B. Anuria.
- C. Hematuria.
- D. Oliguria.
Correct Answer: D
Rationale: Oliguria, reduced urine output, is the most common initial sign of acute renal failure due to impaired kidney filtration.
Which assessment is critical for a client receiving thrombolytic therapy?
- A. Blood glucose.
- B. Blood pressure.
- C. Temperature.
- D. Cholesterol level.
Correct Answer: B
Rationale: Blood pressure is critical to monitor during thrombolytic therapy to prevent hemorrhagic complications.